C8517 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
APPLICATION & PERMIT
aw we
ADDRESS
O� UILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S x PL ECK VALIDATION
7 NAME �f _ OTY. ELECTRIC PERMIT FEE
yj
CON R TORS
r NAME r �� UTLETS-SWITCHES-RECEP 10.00/1.00
sac.ND. 3' LIGHTING FIXTURES 10.00/1.00
. N c aR' PPLIANCES-RESIDENTIAL 4.00
ADDRESS ,A Gy�/
6 ,(/Usk E/e/ ✓✓AONF PANELS 10.00
DATE OF APPLICATION
0gwlrecT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT s.ob PERMIT VALIDATION
ADDRESS
zip TEMP. METER OR POLE INS. 20.00
APPLICANT'$ MOTORS SEE FEE SCH.
ADDRESS '//�J /V�Ip
SERVICE CHANGE 20.00 s
woo LICIiNS11)CONTRACTORS DECLARATION TEMP.POLE 30.00
a is I 1 hereby affirm that I am licensed under provision,of Chapter 9 o
ISSUANCE GATE
y a o`r (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H m Professions Code,an y license is in lull force wu1 effect. U
z0 'b License Clax c.Number -
, Z ' 0),H Date�� Contractor
Q Y E J
OW
ac c a 'Ii R.BUILDER DECLARA N BUILDING PERMIT
co i 0 INFORMATION
X
; y I hereby affirm that 1 ren exempt from the Contractor's License MISC.- REFER TO ORD
u o j Law for the following reason.(Sec.7031.5,Business and Professions
VALUATION $/FT.
_ ,PERMIT ISSUANCE 10.00 /O OQ0
Code:Any MY or county which reqstructres a ure,
prior
it to construct. also
Ca ¢ < O improve,demolish.or repair any.structure,prior to its issuance,also ELEC.OONTR, LIG NO. ELEC. �f, �� /
� a, requires the applicant for such,permil to file a signed statement that TOTAL / PERMIT TO
R
N he is licensed pursuant to the provisions of the Contractor's License
Hir
Law(Chapter 9(commencing with Section 7000),,(Division 3 ofthe
a Business and Professions Code)or that he is esenipl therefrom and DTV. PLUMBING PERMIT FEE
¢ FO the basis for the alleged exemption.Any violation ol-Seamm 703 Ls STORIES TYPE CONSTR.
i 3`0 by any applicant fora permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER IEA.) 5.00 � �
Of not more owner
live hundred dollars(my em)',
❑ 1,as owner at theon,property,,,r my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNI
their sole compensation,will(S the work,and the structure is not
Code: dor offered for Sale(Sec 7044,does
Business and Professions DRAINS-FLOOR,ROOF,AR EA,CON D. 5.00
Code:The who
Contractor's License Law does not apply to an owner of
property wlio builds or improves Ices,lir and who does such work FIXTURES-PER TRAP 5.00 sD.FT.FLOOR AREA TOTAL ACREAGE
b em, re Out
ughrote his own empinyor sale,provided that such h uildin-
orunprrenolintended or wthin on year ((,however.the the ow building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
/ or improvement is rob within one year of completion,the owner- GAS EASYSTEM OVER 4 IEA) 200
builder - . - . .
will have the burden of proving that he did not build or ire- BUILDING USE
prove for purpose of ante.). INDUSTRIAL WASTE INTER. 30.00 RES IND BON PB ower
❑ d as owner of the property,he project
contracting with ❑ 11 ID
licensed contractors to construct the project(Sec. does Business LAWN SPRINKLER$- 1 INC 5 V.B. 6.00 SE55OR5 PARCEL NO.
and n owner ns Code:The Contractor's License Law does not apply
toanof property who builds
trimproves
ensed nand who LAWN SPRINKLERS-OVER 5(EA.) 1.00
me Cont for suchLicenectswithacrmtractortsl licensed pursuant to SEWER-SANITARY-STORM EA.2001t/10.00
Tic Contractors License Law. TRACT N0. PARCEL NO:
❑ lam exempt under Sec. ,13.&1'.C.linihis WATER�HEATER W/VENT 6.00
fl'aipn
Owner Date WATER SYSTEM5.00
% ACC.DATE ACC.FILE NO.
WORK ERS'COMPEN'SA"PION DECLARA'I[ON WATER TREATING EQUIP, 5.00 "
I hereby affirm that I heve.a certificate ofconsent tosel Ginsure.
or a certificate of Workers'Compensation Insurance,or a certified / ZONING ENG.SITE NO.
copy thereof(Sce.3800,Lab C.1. . 1
�G Policy No. Company a
0' ❑ Certified copy is hereby CurnlShedy /� aC FIRE SPRINK ENERGYT24
Z Z O Certified copy is filed with the'7cHy in, cfiY1' div o .
O�- Applicant MISC.- REFER TO ORD. YQ NC] Y N�
CC T PERMIT ISSUANCE 10.00
LU - ,CIiRTIIICATIi Op EXEMPTION FROM WORKERS FLOOD ZONE A.L.UF.
W > C04IiNSAT10N INSURANCE PLG.CONTR. LIC.NO. PLG.
CL D (This section need not be completed if the permit is for one TOTAL Y❑ NC] Y ❑ NE]
hundred dollars IS 100)or less.)
U O I certify that in the performance of the work for which this per, DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- (nit is issued,I shall not employ any person in any manner so as to
0 U become subject to the Workers'Compensation Laws of Califoniia.
LU Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} rn NOTICE 1'O APPLICANT': If,after making this Certificate of fix- _
F 2 emption,you should become subject to the Workers'Compensation I APPLIANCE 5.00 PLAN CHECK
f provisions of the Labor Code, you must forthwith comply with FEE
U' such provisions or this Permit shall he deemed revoked. AIR HANDLING UNIT(TO IOSMC.F.M.) 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 pennit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)Lender's Address ELECTRIC �T s
I certify that I have read this application and rah that the ahove VENTILATION FAN (SINGLE) 4.00 /^
-• information is correct I agree comply with all oily and county PLUMBING ZV
ordinances and state lows relatili ng 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 properly for inspection purposes. BOILER-COMP(Over I00,000 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 mid expenses which CONST.TAX
may ni y�way accrue against wid ity in consequence o the PERMIT ISSUANCE 10.00
may oft ' permit MECH.CONT. LIC.NO. MECH.
TOTALJ. TOTAL r
f(iontmetor Date
INSPECTOR COPY -
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t