9448 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FICATION PERMIT NUMBER
UILDIN ADDRESS APPLICATION & PERMIT 8448
X
I 0q3,4 BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
\ OwNE 'S PLAN CHECK VALIDATION
/ NAME I OTY. ELECTRIC PERMIT FEE
a� vNONE •tea
NAMERAcroR's OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO. LIGHTING FIXTURES 10.00/1.00
CON
TRACTOR oRs
ADDRESS PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENG, PERMIT CIRCUIT 5.0Q PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
AMOTORS SEE FEE SCH. // J
DRESS Ess
ADOR
SERVICE CHANGE 20.00
0 0 o LICENSED CONTRACTORS DECLARATION TEMP,POLE 30.00
M i uhereby aflinn that f:un licensed under provisions oChapmr'I ISSUANCE DATE
(commencing mencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
I F w z Professions Code,and nay license is in full force and effect. El ❑ ❑ ❑
z o w - License Class Lic.Number
o z - Date Contractor
F ~ J
a m s - BUILDING PERMIT
¢ ¢o OWNER-BUILDER DECLARATION INFORMATION
st g ¢-N-' I hereby atftnn that I am exempt from the Contractor's License MISC.- REFER TO ORD
F o o J Law for the following reason.(Sec.7031.5.Husinessand Professions PERMIT ISSUANCE 10.00 vALunT10N 8/FT.
Code:Any city or county which requires a permit to construct,alter,
rt ¢ o improve,demolish,(it repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
- ¢ requires the applicant for such permit to file a signed statement that TOTAL
-.6 w m a he is licensed pursuant to the provisions of the Contractors License PERMIT TO
,- i> Law(Chapter 9(commencing with Section 7000)ofDivision3ofthe
a Business and Profession,Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
fro
¢ F e the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
aim by any applicant for a permit subjects the applica t to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
0' I,as owner of Ore property,or my employees with wages az BACK FLOW PROTECT.DEVICE 4.00 OCC.caouP 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,COND. 5.00
Code:The Contractor's License Lew does not apply to an owner of n
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve .
ments are not intended or offered for sato.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 (EA) 200
builder will have(h - . - . .
e burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 3000 RES IND CON PB Omer
11 .
I,as owner of the property,um exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sea 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law dues not apply
,to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts for such projects with a coutmetoRs)licensed pursumit to
the Contractor's License law. SEWER-SANITARY-STORM EA.2001t/10.00 TRACT No. PARCEL NO.
❑ Iamexemptu cr S. nA ,B.&P.C.for this WATER HEATER W/VENT 6.00
or
\ Owner WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO,
W' RAL S'C0. IiN TION DECLARATION WATER TREATING EQUIP. 5.00
1 here ,atfirm that I h., r erlif¢ale ofconsenl to self-insure, ZONING or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sec.3800,Lub.C.).
Policy No. Company
❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y❑ N❑ Y ❑ N❑
W CF-RTIFICA'IT OP EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10,00 0" FLOOD ZONE A.L.U.C.
L COhIPEN\ ATION INSURANCE PLG.CONTE. LIC.NO. PLG. / (}q V F] NEI V E] N❑
CL Z (This section need not be completed if the permit is for one TOTAL (O
hundred dollars(S 100)or less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
L H ntit is issued, I shall not employ any person in any mmnner so as to
OW Nemne Subject to the Workers'Ccmperosellon laws of California.
ED Uare Applicata BUILDING
>_ N NOTICE TO APPLICANT: If,after making this Certificmn of Iix- ALTER OR ADD TO MECH. 5.00
Z_
empt ion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must fordwilh comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there 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.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Acidic HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
ss
I certify that I have read this application and slate that the above V ENTILATION FAN (SINGLE) 4.00 av
. information is correct. I agree to comply with all city and county BOILER-COK(P(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 100,000 BTU)SEE FEE SCH. MECHANtCAL
above-mentioned property for inspection this
purposes.
(We) agree to save, indemnify and keep hornless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any w' a n '' t said City in consequence of the PERMIT ISSUANCE 10.00
gra fthi PCr t' M ECH.CONT. LIG NO. MECH.
TOTAL TOTAL
igna reo Ap ca tractor etc
Z INSPECTOR COPY