C8457 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT 1 DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT A
ADDRESS 8457
BUILDING - ELECTRICAL-PLUMBING-MECHANI L
OWNER' ze , - PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
I (� cI HONE -
c cTo .f , 61- ^J 9 0 OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME (� R T��9 �.J
LIC.No. LIGHTING FIXTURES 10.00/1.00
CONT
ADDRESS croR's PPLIANCES-RESIDENTIAL 4.00
------- - PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT , PANELS (OVER 200 AMPI 20.00 PLAN CHECK FEE P.C.NO..
OR
ENGINEER
r,....�..� uc No. SIGNS TRANS. 3.00
AEENG. PERMIT VALIDATION
'
ADDRESS
ss SPECIAL CIRCUIT 5.00 ,
zm rrEMP.METER OR POLE INS. 20.00
ADDRESS MOTORS SEE FEE SCH.
ADDRESS J
..�.�� SERVICE CHANGE 20.00
oO o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
M, is� I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
m G w (<ommcncing with$,,lion 7000)of Division 3 0l tlhc Business and "+n BLDG. ELECT. PLG. MECH.
H y z I'rolessions Code,and my license is in full force and effect. ;H
zo•a - License Class Lic.Number
0 z - D DarC Contractor
i2 se
¢ m E BUILDING PERMIT
¢ ¢ w a R
OWNE -BUILDER DECLARATION
D INFORMATION d
woA MISC.- REFER TO ORD
u-m I hereby affirm that 1 con exempt from the Contractor's License VALUATION $/FT.
u o a Law for the following reason.(See.7031.5.Business and Professions PERMIT ISSUANCE 10.00
� - Code:Any city orcounty which requires a permit to construct,site,,
`Q r /j
Q Q a 0 Improve,demolish,or repair any structure,prior to its Issuance,also ELE0.CONTR. LIC.NO. ELEC. `+/001 ,
0 LL RIIUues the applicant fOr SUCh permit to file a Signed statement that TOTAL PERMIT TO /
w m he is licensed pursuant to the provisions ed the Contractor x License
h- zQ Law(Chapter 9(commencing with Section 7000)of Division 3 o(the
Io sins and Professions Cii or that he is exempt tm herefroand QTY. PLUMBING PERMIT FEE
K1- 0 the basis for the ullegttl exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
n ;� by any applicant for a ennit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 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,GOND. 5.00
Code:.The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SD,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such inmlrove-
ments are not intended or offered for sale.If,however,file budding GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the ownerGAS-EA.SYSTEM-OVER 4 (EA.) 2.00-
builder will have the burden of proving that he did not build or - BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 RES IND CON PB Omer
❑ I,as owner of the property,am exclusively contracting with . .
❑ ❑ ❑ ❑ ❑
licensed contractors m construct the project(Sec. 7044, Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Cod,:The Contractor's License Law does not apply
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 contractods)licensed pursuant to ]SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ loco exempt under Sec. .B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner`•+ Date WATER SYSTEM 5.00
ACG DATE ACG FILE NO.
WORK I'RS'COM PENSAT ION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I Imvc a certificate of consent to sill-insure, ZONING
arra certificate of Workers'Com,emsetion Insurance,or a cerlitied ENG.SITE NO.
copy thereof(Sea 3800,Lah.CJ.
Policy No. Company f
0- ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY/T 24
Z 2 ❑ Certified copy is fled with the city inspection division. MIS,.- REFER TO ORD.
O Applicant Y❑ N❑ Y ❑' N❑
cc: N CERTIFICATE OI'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZOrvE A.L.J.C.
LU �_ COb1PENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL Y❑ N❑ Y❑ N
O 1'I'his section need not be completed if Ore permit is for one TOTAL
=) 2 hundred dollars IS 100)or lass.)
U O 1 certify that in the pert'onnunce of the work for which this per- CITY MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mit is issued, I shall not employ any person in any mminer so as to
U W become subject to the Workors'Compensation Laws of California.
Date Ah licant BUILDING
} Do NOTICE:TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
Z coalition,you should become subject to the Workeri Compensation 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=C.F.NL) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that tire,, 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 UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and state 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-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to Corer upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep handless the City of MISC.- REFER TO ORD,
Cupertino against liabilities,just cots, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way a •rue against aid City in consa once of the
grand •this per t. MECH.CONT. LIC.NO. MOTAL
si , til; D r Dr TOTAL b
INSPECTOR COPY