8761 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
AooRLL
III
g- BUILDING-ELECTRICAL-PLUMBING -MECHANICAL 8
76
1
OWS
A PLANCHECK VALIDATION
NAME. - QTY. ELECTRIC PERMIT FEE
Qi ONE37C�r
ArvTRAcaoRs
NAME UTLETS-SWITCHES-RECEP 10.00/1.00
N
LIC,NO. LIGHTING FIXTURES 10.00/1.00 '
CTRACONTRA ions
ADDRESS APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
RCHITECi PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE PC.NO.
OR "
O
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG. IAL CIRCUIT S.QQ PERMIT VALI DATION
ADDRESS
ZIP WO TEMP.METER OR POLE INS. 20.00
TS
APPLICANMOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
w0 0 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
¢is u I hereby'afflnn that I am],crowd under provisions of Chapter 9 ISSU CE DATE
a z an (comencing wish Section 7000)of Division 3 of the Business and BL E PLG. MECH,
a " man
Professions Code, d my license is in full force and effect. ��
Z 0 w- Liecnse Class Lic.Number
4ww Dute Contractor '
H
¢ y r RL NG PERMIT
¢ ¢ w a OWNIi R-BUILDER DECLARATION INFORMATION
E:
; I hereby affirm that I um exempt from lhe Contractor's License
cl MISC.- REFER TO ORD
u ri. V LUATION $/FT.
F u_0Q Law for the following reason.(Sec.7031.5.Businessund Professions PERMIT ISSUANCE 10.00 /
Code:Any city or county which requires a permit to construct,alter,
ia¢ Q 2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
- O ¢ requires the aPPlicanl for such permit to file a signed statement that TOTAL PERMIT TO
A w m he is licensed pursuant to the provisions of the Contractor's License '
Hsi Law Chew,9(commencing with Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ o the basis for the alleged exemption.Any violation of Section 7031.5 1 ISTIBIRIESZTYPE CONSTR.
le
Ate _ by any applicant for a permit'objects the applicant toaCivil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).1:
❑ I,as owner of the property,or my employees with wages asggCK FLOW PROTECT. DEVICE 4.00 OCC.GRO R 5
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code,The Contractor's License Law does not apply to an owner of
property who builds ur improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT,FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such.nnprove- GAS-GAS -11NC.40UTLETS 6.00
Orients are not intended or offered for sale.If.however,the building
or improvement is sold within one year of completion, - . .) 2.00 the owner- GAS EASYSTEM-OVER 4 IEA
budder will have the burden of proving that he did not build or im- BUILDING USE
CO
Prove for purpose of tile.). INDUSTRIAL WASTE INTER. 30.00 RES IND N PB Other
El ❑ E]
❑ L as owner of Oeo le property,ilexclusively contracting with
licensed contractors 10 construe the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC$V.B. 6.00 SSESSORS PARCEL NO.
t of Professions Code:The Contractor's License Law does not apply
toan trowner of property builds trimproves thereon,andwho LAWN SPRINKLERS-OVER 5(EA.) 1.00
commetsctor'ssuch
cenprojects withacommctor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law, TRACT NO. PARCEL NO.
❑ I am exemptunder Sec .e.&P.C.for mit WATER HEATER W/VENT 6.00
(1w Dat WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO.
WORKIiRS•COMPBNSA'ITON DECLARATION WATER TREATING EQUIP. 5.00
I hereby atfirn that I have a certificate DI consent to self-uontc, ZONING
or a certificate of Worker;Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sec 3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
z Z ❑ Certified copy it filed with the city inspection division.
F O Applicant MISC.- REFER TO ORD. Y❑ NE] Y ❑ NE]
CC y CER'1'119CA'I'C 017 EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LOU CONI I'IiNSAT10N INSURANCE: PLG.CONTH LIC.N0. PLO. Y N Y[:JN�
CL z (' 1"his section need not be completed if the permit is for one TOTAL
hundred dollars(S 100)m less.)
U O 1 certify that in the performance of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued. I shall not employ any person in:my mmnner so as to
O become subject to the Workers'Compensation Laws of California. BUILDING
W D.te Ap1'lunut ALTER OR ADD TO MECH. 5.00
} N NOTICE'I'O APPLICANT: If,after making this Certificate oC Iix-
F Z ecnption,you should become subject to the Worker;Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Luber Code, you must forthwith comply with FEE
U such provisions or this permit shall be dremed revoked AIR HANDLING UNIT(TO I0=r-F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction landing agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Cie.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that l have read this application an d state that the above VENTILATION FAN (SINGLE) 4.00
m
• inforation is correct I .gore to comply with all city and county PLUMBING
ordinances and state laws relating to building <onstn¢'I" and BOILER-COfu1P(3H.P.Or1OO,000B.T.U.) 6.00
hereby au0lnrine representatives of this city to enter upon One BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to are, indemnify and keep I nolets Ore City of MISC.- REFER TO ORD.
Cupertino .,.just liabilities,judgment,, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of[he
granting of this permitMECH.CONT. LIC.NO. MECH.
.� . ' & _!;rTOTAL TOTAL
Siy4lature of Applicant/Ct etor�l'e
INSPECTOR COPY