8324 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FI CATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 1)
ADDR ss /1
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 8024
OWNER
•v PLAN CHECK VALIDATION
NAME TY. ELECTRIC PERMIT FEE
/ PNONE
NAMERACT UTLETS-SWITCHES-RECEP 10.00/1,00
IM c.No. LIGHTING FIXTURES 10.00/1.00
ADDRESS APPLIANCES-RESIDENTIAL 4.00
PHONE / PANELS 10.00 DATE OF APPLICATION
PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ORARCHITECT-
ENGINEER
LIC,NO, SIGNS TRANS. 3.00
r mope s era SPECIAL CIRCUIT 5.OQ PERMIT VALIDATION
zmEMP. METER OR POLE INS. 20.00
Avvucnrrs ,J MOTORS SEE FEE SCH. j J
ADDRESS !
SERVICE CHANGE 20.00 r '
wo o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a u I hereby affirm that I am liecowd under provisions of Chapter 9 ISSUANCE DATE
"' (commencing with Section 7000)of Division 3 ol'the Business a I
so BLDG. ELECT. PLG. MECH.
w i Professions Cod au I y license is in full fore n ee
o i m W License Class Lie.Number-
Date
umber /� 37 ❑/
Dale���Contractor. 4
< r BUILDING PERMIT
¢ ¢w a OWNER-BUILDER DECLARATION INFORMATION
R
0 a. r I hereby ulCirm (fiatI an exempt from the Contractor a License
MISC.- REFER TO ORD
ru04 Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
>f Code:Any cityor county which reyuiresa permit toconstract,alter,
¢ ,¢ a O improve,demolish,or repair any structure,prior to its issuance,also ELEC,CONTR, LIC.NO. ELEC.
¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
K
cs m he is licensed pursuant 10 file provisions of the Contractor's License
� z >
Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe
a Business and Professions Code)or that he is cxemPl therefrom and OTV. PLUMBING PERMIT FEE
FEC the basis lir the alleged exemption.An
¢ ro g P Any violation ofSeclion 7031.$ STORIES TYPE CONSTR.
age by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
.fact more than five hundred dollars(55001.):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCD.GROUP RES.UNITS
their sole compensation,will do the work,and the structure Is not
intended or offered for sale (Sec. 7044, Businessand Professions DRAINS.FLOOR,ROOF,AREA,CON D. 5.00
Code:The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SQ FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenetintendedoruU'eyed l'or sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year,of completion,fire owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or int- BUILDING USE
Prove l'or purpose ofsals.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
O 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed 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 or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a eontractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
0 I um exempt under See.-,B&P.C.I'or this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK F RS'COMPENSA"IIPON DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to elf-insure.
or it certificate of Workers'Compensation Insurancu„or a ceNified ZONING ENG.SITE NO,
copy ther• f(Sec. �Q a�1rC
Policy Nd7.�{;6�ryi�oL!!•11/0,/I_�=
❑ Certlie py 1"l erefiy fw with
the FIRE SPRINK ENERGY T 24
Z 2 ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant V❑ No , V ❑ N❑
LUN CI:RTIFICATCOI'EXEMPI'IONI'ROMWORKI:RS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W� ne COAIPENSATION INSURANCE PLG.CONTR. LIC.NO. TPLO
OTAL O, y❑ N❑ y❑ IN C]
CL 0 (This section need not be completed if the permit is for o
hundred dollars IS 100,or Iv,.) -
U O 1 certify that in the performance of the work for which this per- (ITV MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued, 1 shall not employ any person in any manner So as to
O w become subject to the Workers'Compensation Laws of Califomiu. BUILDING
y Date Applicant ALTER OR ADD TO MECH. 5.00
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most lorihwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT TO 10=CF.NL) 4.00
CONSTRUCT ION LENDING AGENCY AIRHANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is is 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.CJ. 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 cenily but I havt,read this application and sure that the above VENTILATION FAN (SINGLE) 4.00
in formation is correct. 1 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 aulhorirc representatives of this city to enter 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 harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, Costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
'
min any way accrue against said City in consequence of the
kil
this permit. MECH.CONT. LIC.NO. MECH.' OTALTOTAL A pticaul mract Uate
INSPECTOR COPY