8410 (3) 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
ADDRESS
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 8410
�[ D PLAN CHECK VALIDATION
{� NAME QTY. ELECTRIC PERMIT FEE
• AlElall ONE
Co N A ORs OUTLETS-SWITCHES-RECEP 10.00/1.00
LID.NO. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
ADDRESS
gEEOPHONE v- PANELS 10.60 DATE OF APPLICATION
ORCHI cr PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE PC.NO.
NGINEER
LIC NO. SIGNS TRANS. 3.00
ADD Ess ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
zap rrEMP.METER OR POLE INS. 20.00
ASS r$ MOTORS SEE FEE SCH.
APPLICDDREA
SERVICE CHANGE 20.00 (
"i
0 0 o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a Lea U, I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
a (commencing with Seelion 7000)of Division 3 of the Business and
a
a_ (commencing
1'rofesvuns Code and my license is m full force and effect. BLDG. ELECT. PLG. MECH.
H w ❑ ❑
o i w o icense Class Lie.Number
)nm .// Contractor
a x s �
¢ OWNER-BUILDER DECLARATION BUILDING PERMIT
¢ a , �5'
0 o U INFORMATION
U. I- I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
Fu0 J Law for the following rcavnT(Sec.703L$,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
Fy0 Code:Any city or county which requiresa permit to construct,alter,
¢ to Q O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
O ne ca u. requires the applicant for such permit to file a signed statement that TOTAL - PERMIT TO
a w E m he is licensed pursuant to the provisions of the Contractor's License
Hza Law(Chapter 9(commencingwitll Section 7000)of Division 3 oflhe // ./
E 4 0 Business aril Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE (T-' l'f- �F=GLL.
IS r $ the basis for the alleged exemption.Any violation of5eclion 7031.5 STORIES TYPE CONST .
o ; by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN IEA.) 5.00
of not more than five hundred dollars(5500).): -
❑ I,as owner of 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 structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 r
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.ET FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
mentsarenotintendcd oruffercd for sale.If,however,the building GAS-EA.SYSTEM-11NC.4CUTLETS 600 _ (f�
or improvement is sold within one year of cont..letion, the owner- /
builder will have the burden of proving that he did Tro build or mu- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PS `Omer
❑ 1,as owner of the property,um exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCELING.
and Professions Code:'fire Cnmractor's License Law does not apply 1N
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to SEWER-SAN ARV-STORM EA.200ft/10.00
the Contractors License Law. 6T TRACT NO. PARCEL NO.
❑ lam exempt under Sea. ,B.&I'.C.fur this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.OATE ACG FILE NO,
WORKERS'COMPIiNSATION DECLARATION WATER TREATING EQUIP, 5.00
I hereby affirm that I have a certificate of c,ownt to self-insure,
L or a certificate of Workers Compensation Insurance,or a certified ZONING ENG.SITE NO.
/ copy thereof(Sec.3800,La b.C.).
Policy No, CmnpuRy I)II
O ❑ CertifieshL•rchy fumi t' L FIRE BPRINK ENERGY TY4
Z Z q/Cerified cop rs 11`�_d�/��. h the t +s t5 + n MISC.- REFER TO ORD.
Q Applicant Y ❑ NE] Y ❑ N❑
N CERTIFICA'1'1:OI'EXEMPTION FROM WORKERS' PERMIT ISSUANCE lO.OD r- FLOOD ZONE A.L.U.C.
W .IPl'NSAT'� COION INSURANCE PLG.CONTR. LIC.NO. PLG. / OV YE] NE] Y E] N❑
d o (This section need not be completed if lite permit is for one TOTAL
0 Z hundred dollars(S 100)or less.)
U O 1 certify that in the performance of the work for which this per- OTY. 'gMECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall not employ any pcOam in any manner so as to
O L) become subject to the Worker Compensation Laws of California. S
a Date ApplicantALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
FZ cmption,you should bocomc subject to the Workers'Compensmion g APPLIANCE 5.00 l.0 49L PLAN CHECK
provisions of the Labor Code, you must I'orlhwith comply with / FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10AOOC.F.M.) 4.00
CONSTRUCI'IONLENDINGAGENCy AIR HANDLING UNIT(OVER 10,0000.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(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING ON IT 100,000 B.T.U.)9.50 U
Lender's Address ELECTRIC
I certify that l have read this application and state that tie above VENTILATION PAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBINGf�
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 V
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTUI BEE FEE BCH. MECHANICAL
uhovwmentioned property for inspection purposes.
OVS).agree to save, indemnify and keep harmless the 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 City in conseque e f the p•�
granting of tltjs perm it. MECH.CONT. LIC.NO. MECH.
IT
IOTA 701" TOTAL / 7
Si• c A PI
an
ntmct
INSPECTOR COPY