C8503 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LD ING PROJECT I DENTIF I CATION - PERMIT Nu 9ER
BUILDINGAPPLICATION & PERMIT _
ADOREss
BUILDING-ELECTRICAL-PLUMBING -MECHANICAL 503(�i 3 C
OWNER'S PLAN CHECK VALIDATION
^(� QTY. ELECTRIC PERMIT FEE
o PHONAS-S a6OV
CONTRACTOR'S
NAME pQ ,/ OUTLETS-SWITCHES-RECEP 10.00/1.00
U ( 1 uc.}30,�T�S7 y LIGHTING FIXTURES 10.00/1.00
ADDRESS oRs sAd coSP PPLIANCES-RESIDENTIAL 4.00
CONTRACTOR
ovc we AV PHONEZ43_ PANELS 10.00 DATE OF APPLICATION
ARCHITECT P.C.PLAN CHECK FEE NO.
OR PANELS (OVER 200 AMP) 20.00 syn
ENGINEER 'N' 00,5 •'
r uc.No. 7 SIGNS TRANS. _ 3.00
AARCH.OR
DDRESS ENG. nn OO SPECIALCIRCUIT 5.00'•;. PERMIT VALIDATION �0'
• ��f9s PART /TVe .5 zlb S�2L EMP.METER OR POLE INS. + 20.00 1
APPLICANTS
ADDRESS MOTORS SEE FEE SCH.
{
q7�I!(i_/I r1rift
yE S. d SERVICE CHANGE 20.00
0 cc LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
EE in I hereby affirm that I am licenud under provisions of Chapter 9
zISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and BLD ELECT. PLG. MECH.
F N z Professions Code,and my license is in full force and effect. ❑ ❑
z o ,,t - License Class Lic.Number-
C,
umber O z r �,. Date Contractor
sy n f BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DECLARATION
a o L u INFORMATION
. 3: LL N I hereby afllnn that I am exempt from the Contractor's License MISC.- REFER TO ORD
uo< Law for the following rcasom(Sec.7031.5,Businossand Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
- Code.Any city or county which requires permit to construct,alter,
¢ Q improve,demolish,or repair any sl ructure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC.
u w- O u requires the applicant for such permit t0 file a signed statement that TOTAL -49,oP RMIT TO
m w he is licensed pursuant to the provisions of lire Contractor's License
Fz > Law(Chapler9(commencingwith Section 7000)ofDivision 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and QTV. PLUMBING PERMIT FEE
¢ r o the basis for file alleged exemption.Any violation of Section 7031.5 ST O ES TYPE NSTR.
a ; m by any applicant far a permit subjects the applicant m a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(55000.):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCCGROUP rt5
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044. Business and Nofessions DRAINS-FLOOR,HOOF,AREA,COND. 5.00
Code:The C.Inmetur's License Law does not apply to an owner of }t
property who builds or cuproves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE L
himself or through his own employees,Provided that such improve"
hients mself a through
ot or offered employees,
or provided
that such
buil ding GAS-EA.SYSTEM-1INC.4OUTLETS 6.00 di
or improvement is sold within one year of completion, - . -OVER 4 IEA. .00 the owner- GAS EASYSTEM ) 2
builder will have the burden of proving that lie did not build or int- BUILDING USE
move fur purpose of sale.). INDUSTRIAL WASTE INTER. 3000 S IND CON PB Out,
.
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project IS". 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 SSESSORS PARCEL NO.
and Professions Code:*Fire Contractor's License Law docs not apply t
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with it contractor/s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.2001t/10.00 TRACT NO. PARCEL NO.
❑ Ian exempt under Sec.-,B&P,C.lo,flux WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS;COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I herehy affirm that 1 have a certificate it consent to self-insure, ZONING ENG.SITE N0.
or u certificate of Workers'Compensation busy,ounce,or a certified
copy thereof(Sec 3900.Lab.C.1 4:7;10,
Policy No. Company
Q ❑ Certified copy is hereby fmorshed. Firm FIRE SPRINK ENERGY T-24
z Z ❑ Certified cu y'is fled with the city inspectiun division.
MISC.- REFER TO ORD.
O Am) cart - Y ❑ N❑ Y ❑ N❑
= CFRTIP ' rl OF Ex1?nfl'fl N FROM WORKHRS, PERMIT ISSUANCE 10.00 FLOOOZONE A.L.U.C.
LU > CO.MPF-NSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL Z I Flux section need not be completed if the permit is for one TOTAL Y❑ N E] Y[D NE]
hundred dollars IS 100)or Icss.)
U 0 1 certify that in BIc performance of the work lift which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mil is issued.I shall not employ any person in any manner so o
as t
become subject to the Workers'Compensation Laws of California.
ED Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING i
} DO NOTICE TO APPLICANT: If,after making this Certificate of Ex-
? emption,you should become subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Calc, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10M C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.RM.) 6.00 SEISMIC FEE
1 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 HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read [its application andstate that the above VENTILATION FAN (SINGLE) 4.00
information n estate l Is agree li comply with all city ucti county PLUMBING
ordinances and state laws relating m 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-COMPIOver 100,000 BTU)SEE FEE SCH. MECHANICAL
abovo-mm�tioned 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
may in any way accrue against said City in consequence of the
granting [his permit MECH.CONT. . LIG NO. MECH.
If. >'Ip,/ a/ �-9 TOTAL TOTAL
Sr f o p�lcunt/Contractor 'Date
INSPECTOR COPY