C8661 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON P RMIT NUMBER
AD'DRESSs _ APPLICATION & PERMIT �^�
BUILDING-ELbECTRICAL-PLUMBING-MECHANICAL
OWNER'S
NAME ` Ik LAN CHECK VALIDATION
QTY. ELECTRIC PERMIT FEE
ONE .
NA.AMER cr Rs UTLETS'-SWITCHES-RECEP 10.00/1.00 ttt111���
F-o _LIc.No. LIGHTING FIXTURES 10.00/1.00 '
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADDRESS
_ PHONE PANELS 10.00 DATE OF APPLICATION
ORRCMIT T PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARC Ess ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
{
__ ZIP rFEMP.METER OR POLE INS. - 20.00
APPLICANT'S
ADDRESS MOTORS SEE FEE SCH.
/ /�p� �•
SERVICE CHANGE 20.00
'w ir 0 o LICENSED CONTRACTORS DFCLARATION TEMP.POLE 30.00
¢ 0 I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
yz w (commencing with Section 7000)of Division 3 of the Business and
¢ y BLDG. ELECT. PLG. MECH.
H yO z Professions License CIa ode,and my license is in full force and effect. ❑ ❑ E:]z 0 - t'�._Cq� !A v.Number S"�S�
. y Hw Dulne, Contractor -
c -� BUILDING PERMIT
¢ ¢ Q OWNER.BUILDER DECLARATSCINT"TC
A a a 0 INFORMATION
w g A. y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
.. 0 ¢ Law for the following reason.(Sec.7031.5,Businessland Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
140E Code:Anycity orcounty which requires a permit ioconstrucLalter, �O /r
c p Q improve,demolish,or repair any structure,prior to Its issuance,also ELEC.CONTR. LIC.NO. ELEC.
d W m R 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 I
H z i
Law(Chapter 9(commencing with Section 7000)of Division 3 oflhe
Q Business and Professions Coda)or that he is exempt t¢refrom onA QTY. PLUMBING PERMIT FEE
f i 0
¢ H m the hosis for lire alleged exempfion.Any violation of Sectlun 7031.5 R $ T E e STB.-
by any upplicaapplicantfor a parnhif subjcctsthc upPlicaapplicanttonuivil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(8500).)'.
❑ h 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 OCC.GROUP RES.UNITS
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 thereon,and who does Such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
hinhself or through his awn employees,provided that such improve-
mentsarenotintendedorofferedforsale.If,however,the budding 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 the burden of proving that he Aid - . - . .
imnot build or - BUILDING USE
R IND CON PB Other
prove for purpose of tile.). INDUSTRIAL WASTE INTER. 30.00 "�
❑ d as owner of the properly,he exclusively contracting with
licensed contractors od fo construct the priced(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
toProfessions Code: ty Contractor's License Law docs not apply
to tr owner of property who builds or improves used Tuand who LAWN SPRINKLE RS-OVER 5 (EA.) 1.00
contracts for such projects with a comractot sl licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License law. TRACT NO. PARCEL NO.
1,Up
❑ lam exempt under Sec. .tl,&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Dale WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COM PENSA I ION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm firm I hove a clrlificmc ofconsent to scl&insure,
or a certificate of Workers'Cmnpensation Insurance,or u certified ZONING ENG.SITE NO.
copy thereof(Sea 3800,Lab.C.).
Policy N..-Cor........
O ❑ Certified copy is hereby furnished. � FIRE SPRINK ENERGY T24
z Z p� Certified cow' its Bled J�ith city ins Tction division. MISC.- REFER TO ORD.
flicant�- L. ,r�yH�yY N� V N�
CC w CI7lPIFICA'r'E'OcfFT%EMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 PLooD zoNE A.L.U.C.
W > COhIPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. v N Y
4- o (This section need not he completed if the permit is for one TOTAL N
Z hundred dollars(S IO p or less.)
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mitis issued,I shall not employ any person in any annnerso as to
O w become subject to the Workers'Compensation Laws of California.
y
Date-Applicant ALTER OR ADD TO MECH. 5.00 BUILDING ,V
} DO NOTICE TO APPLICANT: If after making this Certificate of Ex-
F Z vnption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
CJ such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.NL) 4.00
'CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.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,Clv,C.) HEATING UNIT(TO 100,000 B.T.U.) 8.00
Under's Name HEATING UNIT(OVER 100,000 B.T.U.)Lender's Address ELECTRIC
I certify that I have read this application and state that tat above VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COME(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP(Over 100,000 BTU)SEE FEE$CH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which pERM1T ISSUANCE 10.00 CONST.TAX
may in any way acerae against said City h wnsaluencc oC the
granting of is pcnI MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL C/ s
.hg " plicanlj nn rector Date
INSPECTOR COPY