8408 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
r BUILDING PROJECT IDENTIFICMW PERMIT NUMBER
T BUILDING APPLICATION & P IT
ADOR ESS
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 8408
OWNER'S PLAN CHECK VALIDATION
t: NAME GTY. ELECTRIC PERMIT FEE
�1 PHONE i
CCATRACTT S ova
.a� NAME �/[�1 / UTLETS.-SWITCHES-RECEP 10.00/1.00
nl
/• LIC.NO. LIGHTING FIXTURES 10.00/1.00
ADDRESS ora PPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
on
OPLHRECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. � SIGNS TRANS. 3.00
ARC A.OR ADDRESS ENG. SPECIAL CIRCUIT 5.00. PERMIT VALIDATION
' ZIP TEMP. METER OR POLE INS. 20.00
APPLICANT
ADDRESS MOTORS SEE FEE SCH. 9
SERVICE CHANGE 20.00 A
ve !/��J�
¢ TEMP.POLE 30.00 J 0
r o O LICENSED CONTRACTORS DECLARATION
G U 0, 1 hereby affirm that 1 ant licensed under provisions of Chapter 9 ISSUANCE DATE
H G w (commencing with Section 7000)of Division 3 of the Business and Be. ELECT. PLG, MECH.
H O z Professions Code and my license is in full force and effect. - ❑ ❑ ❑
z O m-- License Class Q 1 hie.Number -
N H W )ate .:.`COIQJCWr�
s< va J BUILDING PERMIT
a o A,D OWNER-BUILDER DECLARATION INFORMATION
E
g a- H 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
FLLoj Law for the follnwingrcison.(See.7031.5.Businesxand Professions' PERMIT ISSUANCE 1000. SOFT. '
�� Code:Any city or county which requiresapermlt to construct,alter,
VALUATION
SE QUO improve, or mpairany structure,prior to its issuance,also ELEC.CONTH. LIC.NO. ELEC )
i w m¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License
iii Law(Chapter 9(commencing with Section 7000)of Division 3 of'the
i o Business and Professions Code)or that he isexempd therefrom and OTY. PLUMBING PERMIT FEE
¢ I- the basis for the alleged exemption.Any violation of Section 703 LS T 5 E CONSTR.
to
m
e_ by any applicant a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(S5000.):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
Item 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 Law does not apply to an owner of
properly who builds or Improves theicon,and who does such work FIXTURES=P.ER TRAP 5.00 $O.FT.FLOOR AREA TOTALACREAGE
`• himself or through his own employees,provided that such on prove.
mends are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 (EA) 200
builder will have the burden of proving that he did not build or ill . . .
i- BUILDING USE
' prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 REI IND CON PB Other
❑ 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 El 0 El El
ASSESSORS PARCEL NO.
and Professions Code:"rhe Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPR INKLERS-OVER 6 (EA.) 1.00
contracts for such projects with a contractors)licensed Pursuant to $EWER-SANITARY-STORM EA.20011/10.00
v. the Contmetor's License Law. TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec.-,BAP.C,for Buis WATER HEATER W/VENT 6.00
reason
Owner Dom WATER SYSTEM 5.00 ACC.DATE ACC.FILE N0.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hemby affirm that I have a certificate of consent to self-inslm. ZONING
or A ecrlillcam of Workers'Compensation Insurance,or a ee Hilird ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
7 Policy No (.7„Qeylp.y11 /n a 4 AL IG t
U ❑ CcrtI Ted L P a y farnisn6d, �
.. 24
Z Z Cerlilled yip s filed with III city inspection division. FIRESPRINK ENERGYTN
O A ant / MISC- REFER TO ORD. y � N� v ❑ N�
~ ,-lf� KM�s PERMIT ISSUANCE 10.00
•- N CER'fl- YrOF I:% Pfd FROM N'ORK ERS' FLOOD ZONE A.L.O.C.
W > CO MPI?NSATION INSURANCE PLG,CONTE. LIC.NO. PLG. Y N
0 This section need not be completed if tire n
e permit is for or,, TOTAL y N
Z hundred dollars IS 100)or less.)
U O 1 certily that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U ..tit is issued, I shall not employ any Person in any manner so as to
become subject to the Workers'Compensation Laws of California.
U w Datc ApplicantALTER OR ADD TO MECH. 5.00 (N BUILDING
} 0 NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F Z_ caption,you should become subject to the Worker;Compensation APPLIANCE 5.00 PLAN CHECK
prvisions of the Labor Code, you must forthwith comply with FEE
U sushi provisions or this permit sIa11 be deemed revoked AIR HANDLING UNIT(TO 10MC C.F.M.) 4.00
CONST'RUCIION LENDING AGENCY AIRHANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
1 hereby affirms that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the perlormance of the work for 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 UN IT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that l have read this application and slate that lheabove k VENTILATION FAN (SINGLE) 4.00 rN
0 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.or100,000B.T.U.) 6.00
I authorize representatives of this city n enter upon the BOILER-COMP IDver100,00DBTUISEEFEESCH. MECHANICAL Uv
above mentioned property for inspection purposes. i
r (We) agree to save, indemnify and keep harmless the City of MISC.- le REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 ✓'!.. CONST.TAX
may in anyway accrue against Paid City in consequence of the O ./
grant,;• hiS purest. MECH.CONT. LIC.NO. MECH.
/ TOTAL 7 V TOTAL
Sig fi p;cant/C ractdr D [
INSPECTOR COPY