C8648 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY,
I
I BU LDI NG PROJECT I DENTI FICATI ON PERMI NUMBER ''!
EDIDING APPLICATION & PERMIT
ADDRESS ^ 8648
�- Z // BUILDING -ELECTRICAL-PLUMBING-MECHANICA
OWNER' I PLAN CHECK VALIDATION
1
NAME _ CITY. ELECTRIC PERMIT FEE
r C. 7 //- PHONfi Id
�N�ERAcroRs UTLETS-SWITCHES-RECEP 10.00/1.00
/ uc.NO. LIGHTING FIXTURES 10.00/1.00
CONTE ACTORS APPLIANCES-RESIDENTIAL 4.00 '
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT - PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR I
ENGINEER
uO No, SIGNS TRANS. 3.00
ADDRESS era PERMIT 5,00 / PERMIT VALIDATION
t ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS
MOTORS SEE FEE SCH.
•
ADDDRESSDRESS
SERVICE CHANGE 20.00
wO o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
is U I hereby affirm that 1 am licensed under provisions ofChapter 9 m' ISSUANCE DATE
waw (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
,-, m z Professions Code,and my license is in full force and effect. ❑ ❑ ❑
z Orn - License Class Lie Number
o zm- Date Contractor
a m I BUILDING PERMIT
¢ ISIS st O OWNER-BUILDER DECLARATION INFORMATION
w3 I y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION $/FT.
'- O a Law for the following reasca.(Sce,7031.5,Business,nd Professions PERMIT ISSUANCE 10.00
fi40f Code:Any city orcomrly which requires a permit to construct.alter, [-OU
Q a, ¢ 0 Improve,demolish,or repair any'structure,prior t0 its j Smmoe0.also ELEC.CONTE. LIG NO, ELEG �J '
G IS requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w a m he'is licensed pursuant to the provisions of the Contractor's License
E z > Law(Chapter 9(commencing with Section 7000)of Division 3 of the ,
a Business and Pmlfatisioms Code)or that he is esemlpl thcrcfronl and QTY. PLUMBING PERMIT FEE f
si0
the basis for the alleged exemption.Any violation of Section 7031.5 'ST0 IEY '- vPE O STFr
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars(S500).):
❑ 1,as owner of the property.or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work and the structure is not
.1 intended or offered for sale (Sec 7044, liuslness 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 sa FT FLOOR AREA TOTAL ACREAGE
O himself or through his own employees.provided that such improve- .
ments are not intended or offered for sale.If,however,the building. GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 aw WILDING USE
°. build,,will have the burden of proving that hu did not build or an-
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 IND CON Pe Omer
❑ 1,as owner at the property,am exclusively contracting with EE ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 SSESSOHS 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 contractor(s)licensed pursuant Io
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
O -
wner
Own, Dat WATER SYSTEM 5.00 ACC.DATE Ace FRE NO.
I ORKERS'COMPENSA'fION DECLARATION WATER TREATING EQUIP. 5.00
I 4rby uffiml that I have a cerificate ofconsent to self-insure, ZONING ENG.SITE NO.
or a certificate uf.workeri Compensation Insurance.or a certified
copy thereof(See.3800,Lab.C.).
Policy No. Company
� � ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z j❑ Certified Copy is filed with the city inspection division.
FO Applicant MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
cc N I CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOOZONE A.L.U,D.
LU > COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
This section need not be completed if the permit is Iilr one TOTAL v❑ N❑ v❑ N❑
hundred dollars(S 100)or less.),
U O 1 certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
lL H mit is'issued,I shall not employ any person in any manner so as to
O become subject to the Workers Compensation Laws of California. -UJ
Dal Dat, APPlicunt ALTER OR ADD TO MECH. 5.00 BUILDING
} 0 NONCE TO APPLICANT: II',atter making this Certificate of Ex-
F-. ? emptiom,you should become subject to the Wmkx,,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.M,) 4.00
\ CONSTRUCT ION LENDING AGIiNcv AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency I'or 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 certify that I have read this application and slate that",above VENTI LATION FAN (SINGLE) 4.00
• information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws ,dating to building construction, and BOILER-7(3H.P.Or 100,000 B.T.U.) 6.00
hereby authoruc representatives of this city to curer 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 Ilannless
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
granting of this permit. MECH.CONT. LIC NO. MECH.
!' ? TOTAL TOTAL
K
S' utum of Applicant/Contructe, late
INSPECTOR COPY