8370 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER "
rooLDING 1 �- APPLICATION & PERMIT ����
�4.. ADDRESS
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWN PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
PHONE I G L
NAME LTOR'S
NAME � UTLETS-SWITCHES-RECEP 111-00
Ic.No. LIGHTING FIXTURES 10.00/1.00
ADDRESS COTRACions PPLIANCES-RESIDENTIAL 4.00
1 G 1 PHONE LIs5 C 2-1511 PANELS 10.00 DATE OF APPLICATION
ARCHITECT- PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENC. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
zlv TEMP.METER OR POLE INS. SC
AEMOTORS SEE FEE SCH.
ADDRDDRESSSS
SERVICE CHANGE 20.00
w o 2 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 S
< u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
so a H (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F w z Professions Code,and my license is in full force and effect.' ❑ a 1:1
❑o i y G icensc Class Lia Number
a r Dale Contr'umo-/
a m w a OWNER �/ BUILDING PERMIT
U BUILDIiR DECLARA'pION �' INFORMATION.
w O; LL H I hereby al'llren that I am exempt from the Contractor's License MISC.- REFER TO ORD -
.. o ¢ Law for lire following reason.(Sec.7031.5.Business and Professions VALUATION S/FT.
E - Code:An t or count PERMIT ISSUANCE �p0.
Any city y re which requires riot t to ,a],. ELEC.CONTE. LIC.NO.
¢ ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC. / -
0 u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w m„+ he is licensed pursuant to the provisions of the Contr¢tor's License
F z
Law(Chapter 9(Commencing with Section 7000)of Division 3 of lire �. LGC7
s 4 o Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE /
¢ r $ lite basis for pie alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a � by any applicant for a permit subjects the appli
of ncl more Iran five hundred doRUrs(5500).):cant tuacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00 OCC.GROUP RES.UNITS
t 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-
mentsarenotintendedorofferedforsale.If,however,the building GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS EASYSTEM OVER 4 (EA) 2.00
builder will have the burden of proving that h - . - .
e did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB orae,
U I,as owner of the properly,me exclusively contracting with 0 0 ❑ ❑ ❑
licensed contractors to Construct the project(Sec 7044,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor i License Law does not apply
to tub owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contracmrlsl licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Cuntmeloi s License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.for Iris WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK E.RS'COMITNSATION DF.CLARA1[ON WATER TREATING EQUIP, 5.00
1 hereby affirm that 1 have a certificate ofconsrnl to self-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING TING.SITE NO.
copy thercof(Sec 3800,Lab.C.).
Policy Na, 77rrm Pxmy ijn,ye
O ❑ Centred copyRmreby furn,rlfc
z Z ❑ Certified copy fled with the city inspection-division. FIRE$PRINK ENERGY TQ4
FOS !1 H, an C,06 -+ :A 6'F,a�r'66 MISC.- REFER TO ORD. YNo Y [D NE]
� N CFR'11FICcfIi OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU > COhIPE.NSA'I'ION INSURANCE: PLG.CONTE. LIC.NO. PLG � O ❑
d [:]
❑
O ffhis section need not be completed if the permit is for one TOTAL Y N Y N
::) Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mil is issued, I shall riot employ any person in Amy manner so as to
w become subject to the Workers'Compensation Laws of California.
D. Date-Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOFICE '1'O APPLICANT': If,after making this Certificate of E.-
F ? entption,you should become subject to the Workers Comprnsalum APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=r-F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the Ped onrancc of fife 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(OV ER 100,000 B.T.U.)9.50 071
Lender's Address ELECTRIC
I certify that I have read this application and nate 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 construction, and BOILER-OOMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby entioed representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
shove-mentioned property forinsp of th i purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgnwnts, costa and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in comic of the
granting of this permit, MECH.CONT. LIC.NO. MECH.
_SI ^ TOTAL TOTAL
Sign reof App man ontr Cor ate
INSPECTOR COPY .