C8214 y;APP.LICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
�{ PERMIT NUMBER
BUI LDI NG PROJECT I DENTI FICATI
BUILDING APPLICATION & PER
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(X BUILDING - ELECTRICAL-PLUMBING-MECHANICAL8214
DINNER S LAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
- NONE - -
AM r s
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00 Sul
♦ UC.NO. LIGHTING FIXTURES 10.00/1.00 -a!L
CONTRACTOR'S - APPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS
CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00
I% )
zip EMP.METER OR POLE INS. 20.00
APPOCANTSMOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 p
'- w O a LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00La
a o u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
m a w Icommencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
Hoz Professions fasions Code,and my license is in full force and effect. ❑ Li z o so License ClassLic.Number
o m ° Date Contractor 4
a - s �y BUILDING PERMIT
¢ ¢ w ¢ OWNER-BUILDER DECLARATION N INFORMATION
O u 0MISC.- REFER TO ORD
w g LL H hereby:dfirm that I am exempt from the Contractor's License -
F'.Hulowingmason.(Sec.7031.5.Businessamll'rofessions PERMIT ISSUANCE 10.00 W VALUATION $/FT.
o J Law for the fol
Nm Code',Any city or county which requires a permit to construct,alter,
¢ ¢ ¢Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. FLED. 3 6)06- a ¢ reyuires the applicant for Such permit to file a signed statement That TOTAL oT PERMIT TO
w $m he is licensed pursuant to the provisions of the Contractor's License
H i va Law(Chapter 9(commencingwith Section 7000)of Division 3 of the ` _
¢ Rosiness and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
the basis for the alleged exemption.Any violation of Section 7031.5 StCRECS "E'CONST14.
(L' ; m by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(S500f).
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.uNrts
their sole compensation,will do the work,and the structure is nm
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Cade The Contractor's License Law does not apply to an owner of
property who builds or improves fiction,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
-� inent.lf re through his own eelred fors.provided that such inlprovC-
mattarenotintendedorofferedforsale.lf,ed that such
building GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,Due owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or int- RES IND CDN PB Omer
prpV:forpurpose 0f the.l. - INDUSTRIAL WASTE INTER. 30.00 El D El 0
L as owner of the properly,he exclusively contacting with
li d contractors to construct the priced(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
a d I rofessions Code:'I'he Cmutructor'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 contractor(s)licensed pursuant to
the Commuter's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
Cl Imp •ne Ip under xSc. B.&P,C.for cis WATER HEATER W/VENT 6.00 _
reaSall �� .i'"
Owner � Date WATER SYSTEM 5.00 yACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATTON 1)lI LARATION ' WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificates ofconsent to self-insure.
m.certificate of Workers'CompenmZONING tion Insurance,or a certified ENG.SITE N0,
copy thereof(Ser.3800,Lxb.CJ.
Policy No. Contp:my
Q 0 Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y N� Y NE]
~ w PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
� fliRT'1 PICCOf OP IiWION INS FROM WORKIiRS'
' W � ° COMI'IiNSA'1'ION INSURANCE PLG.CONTE. LIC.NO. PLO.
l IL Z (This section need not be completed if the permit is for one TOTAL Y[:] NF] Y ❑ N❑
hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which Ihis per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
W F mit is issued,1 shall not employ any person in any manner so i s ur
O become subject to the Workers'Compensation Laws of California.
0. DateApplicant ALTER OR ADD TO MECH. 5.00 BUILDING G
} m NOTICE TO APPLICANT: If,after making this Certificate of Ex-
iF.. FZ emption,y'ou should become subject to the\Vorkeri 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=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0=C.F.M.),6.00 SEISMIC FEE
i
I hertor es that there is a construction lending agamy for EXHAUST HOOD(WITH DUCT) 5.00 \the peC(onnancnee of the work 1tu which this permit is issued ISea MICROFILM
3097- HEATING UNIT(TO 100,000 B.T.U.) 8.00
Leader's Name me
Lender's Address - HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that 1 have read this application and state 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 In building construction, and BOILER-COfVP(3H.P.or 100,000 B.T.U.) 6.00
hereby autlmroc representatives of this city to enter upon the BOILER-COMP (Ober 100,000 BTU)SEE FEE SCM. MECHANICAL /f'O
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep hamlless the City of MISC.. REFER TO ORD. '
Cupertino against liabilities,judgments, costs and expenses which 01[ CONST.TAX
may in any way accrue against said City in conse imeuce of the PERMIT ISSUANCE .1f1�0
grunting f tis permit MECH.CONT. LIC.NO. MECH.
TOTAL &N TOTAL
XlStghattfirdorx,pln t r Dale
INSPECTOR COPY