8767 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT 8767
ADDRESS
ILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'$ PLAN CHECK VALIDATION
NAME ELECTRIC PERMIT FEE
® DNE
CONTRACtOhft
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
rONTR cT R PPLIANCES-RESIDENTIAL 4.00
{p ADDRESS
I. 5. PANELS 10.00 DATE OF APPLICATION
f ARCM cT PANELS (OVER 200 AMP) 20.90 PLAN CHECK FEE P.C.NO.
OR
'
ENGINEER '
uc.NO SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00
zlv EMP.METER OR POLE INS. 20.00 ,t
Avvucnrvrs MOTORS SEE FEE SCH. , \ ',
ADDRESS
SERVICE CHANGE , 20.00 d//
o O LICENSED CON"TRACTORS DECLARATION TEMP.POLE 30.00 o S
rt i 1 hereby affirm that I an licensed under provisions of Chapter 9 ISSUANCE DATE
N
(conuncoom,with fl
7000)of Divon 3 of the Business anJ BLDG. ELECT_ PLG. MECH.
r N i ['confessions Code,and my Iieense is in full foreel f .c
z a m License Class Lic.Number
o H H w Uatcy- -�- Contractor El
a �a P < 1/1- ' L VI BUILDING PERMIT
¢ ¢ w a ��..YY ff»W '. ILDF;R DECLARATION
p INFORMATION
Bos MISC.- REFER TO ORD
w ;0 N 1 hereby collo that I am exempt from the Contractor's License VALUATION SIFT.
F a_ p a Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
J Code:Any city or county whichrequiresa Permit toamM net.alter,
6 ¢ Q 0' improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
- p ¢ requires the applicant fur such permit to file a signed statement that TOTAL PERMIT TO
_n w m" he is licensed pursuant to the provisions of the Contractor's License
r z a Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe /.�L {J /' _
Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE / rJ O-
2 F p the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a3� by any applicant for it permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(S500)J:
O 1,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,AR EA,COND. 5.00
Code:The Contractor's License Law does notapply to i m owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SYSTEM-1 6.00
Dents are not intended oroffered for sale.If,however.the building
Of improvement is sold within one year of completion.the owner GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
Wilder will have the burden of proving that he did not build or no- RES IND CON PB Oche,
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively comracong with
licensed contractors ns 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 contactods)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Conlmgor s License Law. TRACT NO. PARCEL NO.
❑ l am exempt un der Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Dale WATER SYSTEM 5.00
ACC.DATE ACG FILE NO.
WORKERS'COMPF.NSATION DECLARATION WATER TREATING EQUIP, 5.00
1 hereby affirm that 1 have a certificate of consent to selpo(s�u��r�e,
or ayy certificate of Workers'Compensation Insufuncc; r ar a cV ZONING ENG.SITE NO.
Itpit o •c p n
A�'Ltl1 J Iv here sy l unusllfJ ' _ _ FIRE SPRINK ENERGY T-20
Z Z ❑ Cenifi opY cd wit t ro City inspection d'v'
O Applicant MISC.- REFER TO ORD. v � N❑ v ❑ N�
Fin 4 PERMIT ISSUANCE 10.00 FLOOD ZONE. A.L.U.C.
LU CERTIF ATII E EXEI I PROM WORKIiRS'
W �_ ONI'IiNSATION INSURANCE DLG.CONTR. LIC.NO. PLG. ❑ El ❑ ❑
0- O IThis section need not be completed if the permit is for one TOTAL Y N v N
:3 2 hundred dollars(SI00)or less.), `
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued, I shall not employ any person in any nlannerso as to
U become subject to the Workers'Compensation Laws of California.
n. Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE TO APPLICANT': If,after making this Ccrtifiame of lis-
F 2 enption,you should become subject to the Workers'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 IOPMC.F.M.) 4.00
CONS'TRUC`TION 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
t4;?F'y the jerforniance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lendch Name
H EATI NG UNIT(OVER 100,000 B.T.U.)9.50
Lender's AAddrdress ELECTRIC
I certify that 1 have read this application and stale 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 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 CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
6'IQtmgofthi ennTO
it. MECH.CONT. LIC.NO. MECH.
TAL TOTAL /{oV11
t/ tr ct r Pte -
INSPECTOR COPY
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