9339 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT 8339
X DDRE55
�( BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
O E - PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
DrvE
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
uGNO. LIGHTING FIXTURES 10.00/1.00
I:NTAT - APPLIANCES-RESIDENTIAL 4.00
noon Ess
001
PHONE _ PANELS 10.00 DATE OF APPLICATION
ARC HITECPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO,
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS eNG. SPECIAL CIRCUIT - 5.00 PERMIT VALIDATION
ZIP FTEMP.METER OR POLE INS. 20.00
APPLICANT s
ADDDRESSDRESSMOTORS SEE FEE SCH.
^ _ ,
' SERVICE CHANGE 20.00
wo o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 q pp99��
a v eFj I hereby affirm that 1 am licensed under provisions of Chapter 9 ISS ANCgTE
m a m (commencing with Section 7000)of Division 3 of the Business mail BLDG. ELECT. PLG. MECH.
F w z Professions Code,and my license is in full force and effect. ❑ ❑ El
z o m - License Class �� Lic.Number/
9 Z F 0 Uutc 1 - Contmcto, .^ Z-,___1_�
a se BUILDING PERMIT
IS ¢ a OWNER-BUILDER DCCLARA'1'ION o a" MISC.- REFER TO ORD INFORMATION
w3 LL r- I hereby affirm that I am exempt Nom the Contractor's License
u_ oa Law for the following reason,(See.7031.5.Businessand Professions PERMIT ISSUANCE 10.00 VALUATION SIFT,
L Code:Any city orcounty which requires a permit to construct.alter,
¢ ¢¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. ]
u
- 0¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w m u. he is licensed pursuant to the provisions of the Contractor's License C/AO/R
va Law(Chapter 9(win me Being with Sect ion 7000)of Division 3 of the '\
io Business and Professions Code)nr that he is exempt therefrom and QTY. PLUMBING PERMIT FEE r .✓JA/Y/-FG9
¢ $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
d by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not shore than five hundred dollars($500a)
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the structure is not CC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and ProfessionsDRAINS-FLOOR,ROOF,AREA,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 SO.FT.FLOOR A REA TOTAL ACREAGE
himself re through his own employees.provided that such iso building
meats are not through
or ffend for employeesalc.Iided that r.such
ebudoing GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or inh-
proveforpurpose,ofsale.). INDUSTRIAL WASTE INTER3000 RES IND CON Pe Omer
El 1,as owner,of the property,ton exclusively contracting with . .
❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,BusinessLAWN SPRINKLERS- 1 INC 5 V.B. 6.00 �1 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 contraaods)Becnecd pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Coulructuis License Law. TRACT NO, PARCEL NO.
❑ 1 ant exempt under Sec. ,B.&P.C.for tills
WATER HEATER W/VENT 6.00 0-v
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACE.FILE No.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
/L Copy thercof(Sec.3800,Lab C.).
11 Policy No, Company
I0 ❑ Certified copy is herebystn� fIRESPRINK ENERGYTZ4
z Z .[} Certifiecopy is filed with the city inspection division. MISC.- REFER TO ORD.
t]l A(}tlicxnt Y❑ N❑ Y❑ N❑
~ rn r.. PERMIT ISSUANCE 110 i
DJ CLR7IF ICCO IPATE OFNSATION F EXIIINS ON 1RONM WORKER$'CE PLG.CONTR. LIC NO. _ PLG /� FLOOD ZONE A.LU.C.
d'O (Phis section need not he completed If the permit is fur one TOTAL V❑ N❑ Y[:] NE]
Z lhlntdred dollur5($100)or less,) '
U O I certify that in the perfonnmme of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued, 1 shall But cmploy any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
O i Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} Go NOTICE TO APPLICANT: If,after making this Certificate of Ex-
f- Z entption,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 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE / S
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
(tiMICROFILM
performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I oality that l have read t1u,,plicllinn and emte that the abuva VENTILATION FAN (SINGLE) 4.00
information is correct.I agree to comply with all city and county 'PLUMBING PU
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 in
enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. - MECHANICAL
above-mentioned property for inspection purpoxs.
(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 Of this permit. MECH.CONT, LIC.NO, MECH.
TOTAL TOTAL S 3
Signa re ol`A II n' ntr r ate /*z _
INSPECTOR COPY