8760 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
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BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 8760
Gent S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
5r12,
rFG/7- awK /rrL PRONE] F-fid
NOrynERAcioR'a UTLETS-SWITCHES-RECEP 10.00/1.00
LC.NO. LIGHTING FIXTURES 10.00/1.00
ADDRESS roe's PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
0..CHITECi PANELS (OVER 200 AMP) 20.00 FLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO, SIGNS TRANS. 3.00
ARCH.OR ADDRESS ENG. SPE L CIRCUIT 5,00 PERMIT VALIDATION
ZIP MP. METER OR POLE INS. 20.00
ADDRESS rs MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a o u I hereby affirm that I am licensed under provisions of Chapter
2 w
H < H (Commencing with Section 700Division 3 oBusiness and ISSUANCE DATE
H w z Professions Code,and my licensee i in s in lull force and effect. BLDG. ELECT PLG. MECH.i
z o w - License Class Number
-
Date_Common, +❑ �,
� � o Da
Q y E J
T ¢ wa OWNER-BUILDER DECLARA'T'ION BU DING PERMIT
o A U I14FORMATION
w1 hereby infirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
H L'oj Law for the following reason,(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00 VAEUATION $/FT.
Code:Any City or county which requires a permit to construct aIle,,
oimprove,demolish,or repair any structure,prior to its iszuance,also ELEC.COrvTE. LIC.NO. ELEC.
n m M ii- requires the applicant for such permit to file a signed statement that TOTAL
whe is licensed pursuant to the provisions of the Contractors License PERMIT T
Hisa
Law(Chapter 9(commencing with Section 7000)o'Division 3 oftbe
fi o Business and Professions Code)or that he is exempt therefrom and GTY- PLUMBING PERMIT FEE
a H $ the basis for the alleged exemption.Anv violation of Section 7031.5 S R.
a3 � by any applicant fora pennit subjects the applicanitOacivilpenalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars(S500).):
❑ I,as owner.1 the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the sl ructure 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-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00
Or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose ofsaleJ. INDUSTRIAL WASTE INTER30.00 RES IND CON PB Omer
.
❑ L as owner o1 the property,am exclusively contracting with El El El El El
licensed contractors to construct tire project(See. 7044,Business LAWN SPRINKLER$- 1 INC$ 00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply V.B.. .
to an owner of property who builds or improves tlmreon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contradort to licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lamexemptunder Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
rchson
Own a D;IIy WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENA'IION DFCLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NQ
copy thereoltSec.3800,Lab.CJ.
Policy No. Connp:ury
O ❑ Certified copy is It ere by fumisbed' RE SPOINK ENERGY T-24Z 2 C) Certified copy n Filed with UI ty inspection division.
FO AONL'arylf-�2L � �� [ ti MISC.- REFER TO ORD. y ❑ N❑ v ❑ NE]CC y d✓C11R`1 IFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.c.
lO > (704FNSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
CL O (Phis section need! not be completed it Ili, pennit is IDr one TOTAL V❑ N❑ Y ❑ N❑
:3 2 hundred dollars(SIO0)or less.)
U O 1 certify that in the performance of the work for which this per CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is Issued,I,shall not employ any person in any nu cncrso as to
become subject to tine Workers'Compensation Laws of Calilornia.
LU Date-Applicant ALTER OR ADD TO MECH. 500 BUILDING
>_ W NOTICE TO APPLICANT: If,alter making this Certificate of Lx-
.
eniption.you should become subject to the Worker,'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Coda you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.NL) 4.00
CONSTRUCT ION LI'-NDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the ,,,fano once of the work for which this permit is issued(Sce. MICROFILM
3097,Civ.C.). H EATING UN IT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I crUdy that l have read l his application and stale that the above VENTILATION FAN (SINGLE) 4.00
. information is correct.1 agree to comply with all city and county PLUMBING
ordinances and slate laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00
hereb.how euteorizn representatives ec on city es enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
herebymentioned property torinsp of this
purposes.
(We) agree to save, indemnify and keep harmless line City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses'which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said Cily in conse<rycnce of the
n ti ng of this pennit MECH.CONT. LIG NO. MECH.
is
J✓ TOTAL TOTAL
ngnatureof Ap manticomorrO,, Uatc
INSPECTOR COPY