8301 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT1DENTIFICATION PERMIT NUMBER
BUILAPPLICATION & PERMIT
ADDRESS
8301
AooREss
� � BUILDING-,ELECTRICAL-PLUMBING-MECHANICAL
-0wrvE 'S r PLAN CHECK VALIDATION
NAME CITY. ELECTRIC PERMIT FEE
i .4- PHONE
1i K9
NAME nc7oRs UTLE 10.00/1.00
p / f uc.No. LIGHTING FIXTURES 10.00/1.00
AST
GOHEss a APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT
PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC,NO, SIGNS TRANS. 3.00
AARCH 08
GGRESS ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
I ZIP TEMP.METER OR POLE INS. 20.00
ADDRESr
N $ MOTORS SEE FEE SCH. //�
3
• SERVICE CHANGE 20.00 /G
�ao LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 X 1"/ �s�
a U v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE GATE
y st N (commencing with Section 7000)of Division 3 of the Busivess and B D ELECT. PLG. I MECH.
r m z Professions Coek•and my license is in full forec and effect. ❑ 11 O
o 0 m W License Class Lie Number
Ume Contractor
a Y s BUILDING PERMIT
wa OWNER-BUILDER DECLARATION INFORMATION
' w ;u H I hereby affirm that I anI cxc mpgfront the Contractor's License MISCa,. REFER TO ORD VALUATION $/PT.
Fu Oa Law lot the following reason.(See7031.5,1{usinessond Professions PERMIT,ISSUANCE 10.00
w0J Code:Any city or county which requiresa permit to construct.alter,
I Y ELEC.CONTR. LIC.NO. �
, si O improve,Demolish,or repair any structure,prior to its issuance,also LC
a E
requires the applicant for such permit to file a signed statement that TOETA.L PERMIT TO
F.
he is licensed pursuant to tilt provisions of the Contractor's License
Law(Chapter 9(commencing with Sect ion 7000)ofDiv ision 3 of the ��� �
< Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE ///��� 21
r o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TVPECONSTR.
5,: by by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.( 5.00
of not more than five Imndred dollmrs(5500).):
❑ I,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 than
e work, d 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 not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SG.FT.FLOOR AREA TOTAL ACREAGE
v himself or through Itis own employees,provided that such improve-
mentsare not intended orofferedfor sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion.the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or I. BUILDING USE
prove for purpose of Sale.). INDUSTRIAL WASTE INTER. 30.00 RES 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 ASSESSORS PARCEL NO.
and leofcssions Code The Cantuemh License Law docs not apply
, to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA-) 1.00
contacts forsuch projectswith a contractons)licensed pursuant to SEWER-SANITARYV-STORM EA.200ft/10.00
the COntmetoi s License Law. TRACT NO. PARCEL NO.
❑ lam exempt un E Sec. ,BAVC.for this WATER HEATER W/VENT 6.00
rcuson
Owner Date WATER SYSTEM - 5.00
ACC.DATE ACC.FILE N0,
W'ORKERS'CONIP 56G1oh'1)ECLARATION WATER TREATING EQUIP. 5.00
1 hereby at lll(n' have a cerlificme of consent to sell-insure. ZONING
NO-
or a certificate of Workers'Compensation Insurance,or a certifiedENG.SITE NOQ
copy thereof l Sec.3800,Luh.CA
Policy No. Company
O ❑ Certified copy is hereby furbished FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is fled with the city inspection division.
M ISC.- REFER TO ORD.
p Applicant V❑ N V ❑ N[]
LU -N CI1RT'I FICA 11 ori HI MPTIPROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
CL W COMPENSATION INSURANCE
U RA NCE PLG.CONTR. LIC.NO. PLG. Y El N❑ V[:D NE)- O s section need not be completed if the permit is for one TOTAL
hundred dollars(b 100)or less.)
U O 1 certify that in the performance of lire work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit Is issued,I shall not employ any perwm in any manner so os it,
O w become subject to the Workers'Compensation Laws of California.
y Date ApplicantALTER OR ADD TO MECH. 5.00 BUILDING /v -
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
.. Z eruption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK Z'
provisions of the Labor Cock, you most forthwith comply with
U such prnvisloes or this peon shat[be deemed revoked. AIR HANDLING UNIT(TO 10)000C.F.PA) 4.00 FEE I .�-
CONSTRUCTIONLENDINGAGENCY AIR HANDLING UNIT(OVER 10MOC.F.M.) 6.00 SEISMIC FEE ;J-0,,,
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 C.), HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Nude
Lender's AJdreHEATING UNIT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
ss
I certify that I 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 hadding construction, am! BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby amhorue representatives of this city to enmr upon lire gQILER-COMP(Over t00,0008TU)SEE FEE$CH. 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 PERMIT ISSUANCE 10.00 CONST.TAX
accrue ma in any ay against said City in consequence of the
g }In of tl I mit. ry MECH.CONT. LIC.NO. MECH.
\, t� -A J r� TOTAL TOTAL 7
Signa Mof/A p ca f C ntftori` Date
.INSPECTOR COPY
f�