8463 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
S.ILDING APPLICATION & PERMIT 8463
AODness
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNE 'S - PLAN CHECK VALIDATION
NAME 'T' QTY. ELECTRIC PERMIT FEE
o acro s
NAME J UTLETS-SWITCHES-RECEP 10.00/1.00
4r" fNCaW0. LIGHTING FIXTURES 10.00/1.00
RA Ton's - PPLIANCES-RESIDENTIAL 4,00
ADDREE
PHONE _ PANELS 1O.D0 DATE OF APPLICATION
onC T r PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRESS ENG' SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT'$
ADDRESS MOTORS SEE FEE SCH.
.-- SERVICE CHANGE 20.00
woo LICENSED CON'T'RACTORS DECLARA'T'ION TEMP.POLE ) 30.00 O
c U u I`herehy affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
N , n (commencing with Section 7000)of Division 3 oI'the Business and
< BLDG. ELECT. PLG. MECH.
F H i Professions Code,and my license is in full force and effect.
Z O m - License CP Lie.Contractor r�
O r o� Date sT _Lie Nolo,, i F'
m T Pr OWNER-BUILDER DECLARATION C L BUILDING PERMIT
o d o INFORMATION
w ; LL m I hereby affirm that I am exempt from lire Contractor's License MISC.- REFER TO ORD
LL o j Law for the following reason.(Sec.7031.5.Businessaml l'mfessiore
VALUATION S/FT.
- PERMIT ISSUANCE 1.OJ]0. _
Code:Any city.,county which requirese permit to construct,alter,
aimprove,demolish,o[repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO, ELEC.
al a, o c requires the applicant for such permit to file a signed statement that Itl1 TOTAL Z.�S PERMIT TO
u w m m he is licensed pursuant to the provisions of the Contractor's License
za
Law(Chanter 9(commencing with Section 7000)of Division 3 of the
4o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE G
¢ Het the basis for tire vllegal exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
P. _ by any applicant for a permit subjects the applicant too civil penalty
of not more than Eve hundred dollars($5000.):
ALTER-DRAIN -WATER IEA.) 5.00 -
❑ I,as owner of the property,or my anployces with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC. RES.UNITS
their sole compensation will do the work,and tiro Structure is not
intended nr offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's Lace...c Law docs not apply to an owner of
property who builds or improves t hereon.and who does such work FIXTURES-PER TRAP 5.00 SO,FT,FLOOR AREA TOTALACFtAGE
himself m through his own employees,provided leve such impmve-
Brands Inaodfrenolimendedor employeeffered for sale.provided
Illidsthebuilding GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 (EA) 200
builder will[lave the burden of proving that he did not build Go im - . - . .
- BUILDING USE
Prove for purpose of Sale). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Ome,
❑ 1,as owner of the property,am exelil'sively contracting with 1:1 1:1 1:1 E] Ellicensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds nr improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to SEWER-SAN EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ l ane exempt under Sec ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM - 5.00
ACC.DATE ACC,FILE NO.
WORKERSCOMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby at firm that I have a certificate of consent to`self-insure. ZONING
or a certificate of Workers Compensation Insurance,or a ceaificd ENG.SITE NO.
'-�- copy thereof(Sec 3800,Iab.CU.
Policy No. Company Tg� r�
O ❑ CerGficd copy is hereby far, eU. FIRE SPRINK ENERGY T24
Z
Z gCertificd copy is filed with he city inspection division.
Fip Apphcant--.A.,'.-. 1ecv, ii.__Zrtra MISC.- REFER TO ORD. Y❑ NE) Y ❑ No
cr N CERTIFIC 11:OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LIJ > COMPENSATION INSURANCE PLG.CONTE. ❑c.NO. vLG.
Z (This section need not be completed if the permit is for one TOTAL Y❑ NO Y ❑ N❑
I undred dollars IS 100)or Icsx.)
U O 1 certify that in tine performance of the work Ibr which itis per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
UL U mit is issued, I shall not employ any person in any manner so as to
become subject to tiro Workers'Compensation Laws of California.
0 w Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} w NONCE TO APPLICANT. If,after making this Certificate of Ex.
2 emption,you should become subject to the Workers'Conhperaat ion APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you Borst forthwith comply with FEE
U such provisions or this permit shall be dremed revoked. AIR HANDLING UNIT(TO 10;MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.EM.) 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 or which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATI NG UN IT 100,000 B.T.U.)9.50 ✓ (�
Lcndcrs Address ELECTRIC T
_ I certify that I have read this application and state That the above VENTILATION FAN (SINGLE) 4.00
into Unction is correct. I agree to comply with all city and county PLUMBING
ordinances and stale laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorise representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mmntioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino .,.lost liabilities,judgments, costs'and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
irmay in any way accrue against said City in consequence of thetm,of this periliL • MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
n 'cant/Contmctuf Date -
INSPECTOR COPY
I