8317 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT 1 DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT 8317
ADOREss ,BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
i
Ow R'S PLAN CHECK VALIDATION
"A QTY. ELECTRIC PERMIT FEE
/ oNE
NAE To s OUTLETS-SWITCHES-RECEP 10.00/1.00
LIc.N / LIGHTING FIXTURES 10.00/1.00
r, NTRA 's PPLIANCES-RESIDENTIAL 4.00
ADDRESS
441-
fi _ONE .f{ PANELS 10.00 DATE OF APPLICATION
ARCH TE PLAN CHECK FEE P.C.NO.
on PANELS (OVER 200 AMP) 20.00
ENGINEER
' uc.NO. SIGNS TRANS. 3.00
AARCH.OR DDRESS ENG. .SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
_ZIP EMP.METER OR POLE INS. 20.00 //
0
ADDRESS MOTORS SEE FEE SCH. nLY f
SERVICE CHANGE 20.00 ]T� p `
o o LICENSED CONTRACTORS DECLARA'T'ION TEMP.POLE 30.00 /•�Tv/ 5
¢ u I hereby affirm that 1 on, licensed under pruvisious of Chaplcr 9 ISSUANCE DATE
w < m (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H m z Professions C I m Iinnsc is in toll f J of ❑ ❑ ❑
Z .0-I;
0 m- License Cla Lic.Numh
9 m H w Dare Contractor
a Y EBUILDING PERMIT
¢ ¢ w OWNER-BUILDER DECLARATION INFORMATION
w0 a. w I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION
F LL 0 a Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires upennit l oconstruct,alter,
¢ ¢ improve,demolish,or repair any.structure,prior to its issuance,also ELEC.CONTE, LIC.NO. ELEC.
ca
A w m¢ hesedto c
t ,rCS tl1p orsuanlOr t Suh permit to file a signed statement that TOTAL PERMITTO
p provisions of the Contractor's License �]
Law(Chapter 9(commencing with Section 7000)of Divisfan3 oftle LU
a Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
si0
¢ H$ the basis for the alleged exemption.Any ehe applica o1.action en L5 STORIES TYPE CONSTR.
d 3 by any app than five permit subjects S500).lieant toacivil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00 '
of not more than five hundred Dollars(5500).):
❑ 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 do tire 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 does not apply to an owner of
property who builds or bolooves there n,and who does Such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTALACREAGE
himself re through his own employers, le.If,ho that such improve-
nients himsearenotint®tJcd oroffered mployees.p.lf,ho that mn'"'Proing GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4(EA ) 200 BUILDING USE
builder will have the burden of proving that h . . .
e did not build or int- RES MD CON PB Other
prove 1,as ownerose
of sale.). INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ 11 ❑
❑ d as owner of the property,he exclusively contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Cole:The Contractor's License Law does not apply
to owner of properly who builds o improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts
acts for such projects with a contractors)
Uncdrrts) iccnu.A pursuant kr
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT No. PARCEL No.
❑ I am exempt under See.-,B.&P.C.for this WATER HEATER W/VENT 6.00 AleI
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC,FILE NO.
' WORK ERS'CONIPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure. ZONING ENG.SITE N0.
or a ecNificme of Workers Compens tion I surunee ora-•r iFreJ
copy c, o4:yb ).
Poli ?fydu Y
etllfu opy is hemhy lar lsheJ. - FIRE SPRINK ENERGY T 24
z Z L�ccTificd copy is lilcy,y with the 'It pection division.
O Ap(Iecant ✓/ p 1 MISC.- REFER TO ORD. 4a Y 0 NY NE]
T
CC
Lu CERTIFICIT I
EXEMPTION FROM WORKERS' FLOOD ZONE A.L.U.L.
W COCOMPEE PERMIT ISSUANCE 10,00 NSATION INSURANCE the PLG.CONTE,. LIC,NO. PLG. /U0 Y N Y [] N
� Z hundred
action need not be completes i(the permit is for one TOTAL Q
hundreJ dollars IS 100)or less.)
U O 1 certify that in the performance of the work I'or which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
IL 1- mit is issued,I shall not employ,any person in any manner in,as to
Ow becoma subject to the.Workers'Compensation LawSof C,ofomia. BUILDING
Q. Dat° npphc nt ALTER OR ADD TO MECH. 5.00
} 0 NOTICE. TO APPI.ICANT: If,after making this Certificate of Ex-
Z emption,you should become subject to the Workets 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 AG17NCY AIR HANDLING UNIT(OVER 1000C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
line 3097 performance ance of the work for which this pennit is issued(Sec. HEATING UNIT ITC 100,000 B.T.U.) 8.00
endeh Address nder's Name
LHEATI NG UNIT(OVER 100,000 B.T.U.0.50 ELECTRIC
Lender's
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information ordinances
correct 1 agree to comply with all city and county PLUMBING
oand state laws relating to building construction, and BOILER-COMP 13 H.P.Or 100,000 B.T.U.) 6.00 v
hereby authorise representatives of this city to enter upon the BOILER-COMP (Over 101.000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(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, any way accrue against said City in consequence of the
gran in of th
is permit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Sig reo A50fivalitiCont,acto Dutc
INSPECTOR COPY