C8275 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BII,LD,NG , APPLICATION & PERMIT
REss
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ADDRESS ��sZ75
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OINNEATIT I PLAN CHECK VALIDATION
NAME - CITY. ELECTRIC PERMIT FEE
NAMEHAcroR's UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO. LIGHTING FIXTURES 10.00/1.00
OTORS APPLIANCES-RESIDENTIAL 4.00 '
CONTRA
PHONE• PANELS 10.00 DATE OF APPLICATION
onCHfTECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
Lm.No. - SIGNS TRANS. 3.00
ADDRESS ENa SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
APPLICANTSMOTORS SEE FEE SCH.
ADDRESS
ADDR xvL,
SERVICE CHANGE 20.00 vg
r
00 LICENSED CON TRACTORS DECLARATION TEMP.POLE 30.00
a .w I hereby affirm that I um licensed under provisions of Chapter 9 - ISSUANCE DATE
w a a - (ummmencing with Section 7000)of Division 3 ofthe Business and BLDG. ELEDr. PLG. MECH.
r H i Professions Code,and my license is in full force and effect ❑ ❑ El El
0 m W License Class Lic.Number
Date Contractor Q
Q y 5 J {, BUILDING PERMIT
¢ ¢ w a OWNER-BUILDER DECLARATION INFORMATION
I r 1 hereby affirm that I am exempt from the Contractors License
MISC.- REFER TO ORD
r a_ o J Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
� w Code:Anycity orcounty which requires a permit to constn¢L alter, CJV
SC ¢¢ O improve,demolish,or repair uny structure,prior to Its issuance,also ELEC.CONTR. LIC.NO. ELED, VV
0 c, requires the applicant for such permit to file a signed smlcnrcnt that TOTAL
A w m ha is licensed pursuant to Ilse provisions of the Contr.¢tor's Lnamse PERMIT TO
F z s- Law(Chapter 9(commencingwitit Section 7000)of Division 3 oftbe
4 0 Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ I-o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
La 3`O by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN (EA:) 5.00 e
of not more than f - -
ive hundred dollars(55001.): .,,
❑ I,as owner of the property,or my employees will
cit.ayes as BACK FLOW PROTECT. DEVICE 4.00 OCC. -
their sole compcntion,will do the work,and the structure is not RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law r does not apply to an owner of
properly who milds or Improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTALACREAGE
himse• mem.,me Hot
hde ownemployees,for sale.
howehat veruch,
improve- GAS-EA.SVSTEM-I 6.00 -\
mems are not intended or offered for sale If,however,the building i
or improvement is sob within one year of completion. oil 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 for purpose of sale.). RES INDEl CON PB Ote
❑ I,as owner of the Property, y contracting INDUSTRIAL WASTE INTER. 30.00
p 1 y.he exclusive( a044,Bi with ❑ ❑ ❑ ❑ I f r
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL N0.
to Professions of Code:The Contractor's ticenu Law does not apply
to contracts
owner of property who builds tr improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
the Cont for such License
ts Lwithacontructorls)licenced pursuant to SEWER-SAN ITARV-STORM EA.200(t/10.00
theContractor'snamcexis Li cense Law. TRACT NO, PARCEL NO.
❑ lam exempt under Sea.-,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Ownor - Uam¢ WATER SYSTEM 5.00
.! ACC.DATE ACC.FILE NO.
WOkkERS'COMPIiNSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have u certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE N0.
copy IhemoffSec.3800.Lab.CJ.
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
z Z ❑ Certified copy is filed with the city inspection division. REFER TO ORD.
F O Applicant Y❑ N❑ Y ❑ INC]
N 10.00
-
CERTIFICATEOF EXEMPTION FROM WORKERS' PERMIT ISSUANCEFLOOD ZONE A.Lu.C.
UJ as COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG
d (This section need not he completed if the permit is for one TOTAL V❑ N❑ V❑ N❑
Z hundred dollars IS 100)or lP,,.)
U O 1 certify that in the perforrmance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- Hilt is issued.I shall not employ any person in any manner so as to
O w become subject to the Workers'Compensation Laws of California.
CL Date Applicant BUILDING UC/z
} W NOTICE TO APPLICANT: If,after making this Certificate of fix. ALTER OR ADD TO MECH. 5.00
F Z_ emption,you should become subject to the Workeri Con,pensation APPLIANCE 5.00 PLAN CHECK /
prHvisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IQOOOGEM.) 6.00 SEISMIC FEE
I hereby affirm that time, is a construction lending agency lir. EXHAUST HOOD(WITH DUCT) 15.00
the performance of the work I'or which this permit is issued(Sec MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
- -Lender's Name H EATI N G LIN IT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is cornea. I agree to comply with all city and county• BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00 PLUMBING ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,00_0 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
fate) 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 consequence of the
ting Ofthis permit MECH.CONT. LIG NO. MECH.
TOTAL TOTAL
Co n roc or ata
INSPECTOR COPY ,
I