8759 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 8759
ADOR 55
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME z OTY. ELECTRIC PERMIT FEE
CONTNl G ��./LV.0 PHONES fi-J '
EAmoR's
NAIVE UTLETS-SWITCHES-RECEP 10.00/1.00
NAM
LIC.NO. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
'
ADDRESSRESSPPLIANCES-RESIDENTIAL 4.00
ADDRESS
' PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIc,No. SIGNS TRANS. 3.00
ARCH OR ENG. SP IAL CIRCUIT 5.00 PERMIT VALIDATION
zIvSS
EMP. METER OR POLE INS. 20.00
APPLICANT S SMOTORS SEE FEE SCH.
A
SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30,00
< v U I hereby affirm (hat I am licensed under provisions of Chapter) ISSUANCE GATE
yQ (commencing with Section 7000)of Division 3 of the Business and BLDG. ELEC PLG. MECH.
F w i Professions Code,and my license is in full force and effect. F-1 ❑ El
o m - License Class Lic.Number
o z r Dale Contract.,
a y 5 BU DING PERMIT
as ¢ a OWNFR-BUILDFR DECLARATION INFORMATION
eaoP_ MISC.- REFER TO ORD
wg LL H 1 hereby uffrnt that I um exempt from the Contractors License
u04 Law for lire following Te,son.(Sec 7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
� - 0 Code:Any city orcounty which requires a permit to construct,utter,
ac en Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
K O¢ requires the applicant for such permit to file a signed Statement that TOTAL PERMIT T
A se as he is licensed pursuant to the provisions of the Contractor's License
Fzi
Law(Chapter 9(commencing with Section 70001 of Division 3 ofthe
a Business and Professions Code)or that Ile is exempt therefrom and OTV. PLUMBING PERMIT FE
¢ r o the basis for dm alleged exemption.Any violution of Section 7031.5 5 IE CO
A g by any applicant for u pcnnit subjects Ihu applicant tea civil penalty
of not more lir...five hundred dollars($5000:
ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ h as owner of the property,or my enmloyces with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC,GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or Improves thereon,and who does Such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees.provided that such improve-
.cuts are not intended or offered for sale.ll',however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or int- BUILDING USE
prove for purpose of sale.),• INDUSTRIAL WASTE INTER. 30.00 ES IND CON PB Omer
❑ I,as owner of tire property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contruclors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner(if property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 1EA.1 1.00
contracts for such projects with a contracloGO licensed pursuant to
the Contractor's LiccnseLaw, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ 1u.exemptunder Seo. .T&P.C.for IN, WATER HEATER W/VENT 6.00
Gas if
0.I / 'f.4:4Da WATER SYSTEM 5.00 ACG DATE ACC FILE NO,
W'ORKF RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy thc,eofi Sec.3800.Lab.C.L
policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z D Certified copy (s filed with the city inspection division. MISC.- REFER TO ORD.
0 Applicant Y ❑ N❑ V ❑ N❑
y CE RTI F I CA'rh 61:EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU > COM1IPE.NSATION INSURANCE PLG.CONTE. LIC.NO, PLG. YO NE] Y ❑ NE]
Z (This section need not be completed if the permit is for one TOTAL
hundred dollars IS 100)or Ic.T
V 0 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY'
LL I- mit is issued,1 Shull not employ any person in any manner so as to
U becorne Subject to the Workers'Compensat ion Laws of Culifomia. -
Ul Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} A NOTICE TO APPLICAN"I: If,atter making this Certificate o0IEx-
Z emptier,you should accent,subject to(lie Workers'CongwnsuNoo APPLIANCE 5.00 PLAN CHECK
provisions of (he labor Code, you must forthwith comply with FEE-
V such provisions or this permit shall be demncd revoked. AIR HANDLING UNIT(TO 10)000CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MIC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(See. MICROFILM
3097,Civ.C.L HEATING UNIT ITR 100,000 B.T.U.) 8.00
Lender's Num.
Lender's NAdd.ame HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I Certify that l hive read this application and State that the above VENTILATION FAN (SINGLE) 4.00
• information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building consume[ion, and BOILER-COIVP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE BCH. MECHANICAL
above-mentioned properly for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs andexpenses which CONST.TAX
Cray in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
�Ianl ing of 110 ispermit. _ MECH.CONT. LIC.NO. MECH.
/ TOTAL TOTAL
Signature of ApplicanllC nu' toy Dalc
INSPECTOR COPY