C8663 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY'
PERM17 NUMBER
BU I LDING PROJECT IDENTIFICATION APPLICATION & PERMIT
BUILDING
ADDflE55 (�
o (nu� S fl BUILDING-ELECTRICAL-PLUMBING-MECHANICA o V8 0 6
_ O NE 'S i PLAN CHECK VALIDATION
NAME '� i OTY.
NAME ELECTRIC PERMIT FEE n
•� PHONE 1
ncroR's UTLETS-SWITCHES-RECEP
y 1 jJ
CNTH ea
c.No. LIGHTING FIXTURES 10.00/1y00
\ ADDRESS. PPLIANCES-RESIDENTIAL 4.00
ppRE
`+r•THONE k'-J PANELS 10.00 DATE OF APPLICATION
RRGHITECT PANELS (OVER 200 AMP) 20,06 PLAN CHECK FEE P.C.NO.
O
ENGINEER
' Llc.No. SIGNS TRANS. 3.00 '
ARCH.OR EN f PERMIT VALIDATION
ADD.Ess t SPECIAL CIRCUIT 5.00
ZIP EMP. METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
APPLICA rs
SERVICE CHANGE 20.00 /
r° a TEMP.POLE 30.00 C yz� 3�d3�
02 LICENSED CON]'RACTORS DECLARATION
FZ W I hereby affirm that I am licensed under provisions of Chapter 9 +7 ISSUANCE DATE
a $ (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F w z Professions Code,and my license is in full force and effect 4 ❑ ❑ ❑ ❑
oz m W License Class&1 G 1.( Lis.Number
r u,r• la Dale 7 -t S - � Contrado
a y f BUILDING PERMIT
tc ao i° OWNER-BUILDER DECLARATION INFORMATION
R
LL H 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u O j Law for the following reason.(Sec.7031.5,Business and Professions ALUATION SIFT.
_ PERMIT ISSUANCE ��
Code:Any city or county which requirese permit to construct,alter.
QQ 40 IlnplpVQ den101SM1,or f[pall any SlrllCtnR,prior to ItS IS511anef.also BLED.CONTE. LIG NO. ELEC. �I �/ ��
an °¢ requires the applicant for such permit to file a signed statement that TOTAL
d w es u- hPERMIT TO
e is licensed Imellmnt to the provisions of the Contractor's License r / T
F z i
Law(Chapter 9(commencing with Section 7000)of Division 3 of the JD� v `FTG�M
A
Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ t$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES YPE CONSTR.
03 - by any applicant for a permit subjects the applicant toacivil penalty ALTER-DRAIN IEA.) 5.00
of not more than five handled dollars(S500).1:
❑ 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 Jo 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 docs not apply to an owner of
ProperfY who builds Or improves thereon,and who does such work FIXTURES-PERTRAP 5.00 SO.VT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If however,the
building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improver eat is sold within one year of completion, the owner- GAS-EASYSTEM-OVER 4(EA) 200
builder will have the burden of proving I . . .
M1m he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 RES IND CON PB Other
0 1,as owner of m . .
the property.aexclusively contracting with ❑ -❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SP INKLERS-1 INC 5 V.B. 6.00 ' ASSESSORS PARCEL NO.
and Professions Code:'I'lie Contractor's License Law Joes not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects willh a contractor(s)licensed pursuam to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
0 Iamcx.Ilitundcr Sec. .B.&P.C,for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPFNSA'IION DECLARATION WATER TREATING EQUIP, 5.00
I hereby infirm that I have a certificate of consent to sel Linsure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec,38 00 y � ��. s
Policy No Chin ony ba e I "
0 0 CerNfieA copy is hereby furnished.
Z 2 ��Certified Copy is fi wl- ith the city f�sypyp{yL[W;ision. s FIRE SPRINK ENERGY L24
O"C A*, Gant MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
~ N FTF PERMIT ISSUANCE 10.00
CIi If III FIC"I'B OP Ii XIiM I'l'IUN PROM WORKIiRS' FLOOD ZONE A.L.U.C.
Ui > COMPENSATION INSURANC17 PLG.CONTR. LIC.NO. PLG
Z (Chis section need not be completed if the permit is for one TOTAL �� ) Y❑ N❑ Y ❑ NEIN
hundred dollars($100)or le".)
V O 1 certily that in the performance of the work for which this per. OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H- mil is issued,I shall not employ any person in any manner so as to
O U, become subject to the Workers'Compensation Laws of California.
Date A Ilam BUILDING
} N NOTICE 'r0 APPLICANTI.If,after making this Certificate of nix- ALTER OR ADD TO MECH. 5.00 'J
F Z emptioq 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 10PMC.F.M.) 4.00 '
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 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(See. MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT 100,000 B.T.U.)9.50 /
Lender's Address ELECTRIC
I certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county. PLUMBING
ordinances and slate 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 to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(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 10.60 CONST.TAX
may in any way accrue against said City in consequence of the
gruntingof this Bern.it. MECH.CONT. LIG NO. MECH.
J - TOTAL TOTAL
IgnalTIT of ApplicantiContractor Date
�''� INSPECTOR COPY