8326 APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING,PROJECTlDENTIFICATION PERMIT NUMBER
APPLICATION & PERMIT
BUILDING
AOO Es 9,a lccg�ON 14
BUILDING - ELECTRICAL--PLUMBING.-MECHANICAL 8326
E PLAN CHECK VALIDATION
rvgmE Y. ELECTRIC PERMIT FEE
PHONE
N E'CONTRACTORs OUTLETS-SWITCHES-RECEP 10.00/1.00
LICNo. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4,00
.{y PHONE - /O PANELS 10.00 DATE OF APPLICATION
OR° TET PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P,C.NO.
ENGINEER
' LIC.NO, SIGNS TRANS. 3.00
ADDRESS Enc' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP. METER OR POLE INS. 20.00 %
APPLICANTS MOTORS SEE FEE SCH. /
ADDRESS
SERVICE CHANGE 20.00 1 '�-
wO o LICENSED CONTRACTORS DECLARATION TEMP. POLE 30:00 ! 11
a u I I hereby affirm that I am licensed under provisions of Chapter 9 - ISSUANCE DATE
HZ i (commencing with Section 7000)of Division 3 of the Business and
a BLDG. ELECT, PLG. MECH.
"' Professions Co license is in full fore r f
Z o w z License Class_ Lin.Number ❑
OZ Z r O Da(c Contmmor
`a Y BUILDING PERMIT
0 n a OWNER-BUILDER DECLARATION INFORMATION
W ; acF I hereby affirm that I ant exempt from the Contractor's License MISC.- REFER TO ORD
r- .. o a Law for the following reason.(Sec.7031.5,dusinessund Professions PERMIT ISSUANCE 10.00 VALUATION
Code:Anycity orcounty which requiresa permit toconstrucl..l ter,
a � ELEC.CONTR. LIC.NO.
¢ a p improve,demolish,or repair any stnmlurC,prior to its issuance,also ELEC.
Ic
R m u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
Ca whe is licensed pursuant to the provisions of Oce Contractor's License
H Z i Law(Cheptcr9(commencing with Section 7000)of Division 3 of the t / _
a Business and I'rofcssions Code)or that he is exempt thernlrom and OTY. PLUMBING PERMIT FEE I
¢ r o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
n35 by any applicant for a permit subjects lire applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred doll...(5500).):
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEVICE' 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for .a]c JScc. 7044, Business and Prnfcssions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
' property who builds Or improve.thereon,and who does such work FIXTURES-PER TRAP 5.00 SQ FT.FLOOR AREA TOTAL ACREAGE
oundsare not hrough
own employees.
Sale,1i,ed however,(lie
improve- GAS-EA.SYSTEM-11NC.4 OUTLETS 6.00
mems are not imended or offered for anlc IL hnweveq the building
or builder
wicnmm is sold within one your of clic did ion,the owner. GAS-EA.SYSTEM:OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not buil)or inr. BUILDING USE
move for purpose of the.). INDUSTRIAL WASTE INTER. 30.00 RES IND DON PB Omer
❑licensed as owner of the property,um exclusively. 7044, Eng with ❑ ❑ ❑ ❑ ❑
adPro contractors 10 construct the project(Sec. 7044,of apply LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions property
The hbuildContractor's License Law docs not apply
co an owner of property who builds tr improves rased In..nd who LAWN SPRINKLE RS-OVER 5 (EA.) 1.00
contracts Cntractor', cense Lwithacontramorlsl licensed punuantm SEWER-SANITARY-STORM EA.200ft10.00
the Conhaelois License Law. / TRACT NO. PARCEL NO.
❑ lam exempt under See. ,B.&P.C.for this WATER HEATER W/VENT 6.00 0 Q
reason
Owner Data WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSAT'ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a ecnilicxu.•of consent to selt-insurC.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.•
copy there f b.C.l.
Policy FN�- � /any_
Q ❑ rt li ray Is ercby furnis ud.
FIRE BPRINK ENERGY T 2
z Z Certified o filed with the city inspection division.
Fp A Ivan, REFER TO ORD. v❑ No , v ❑ N❑
tw PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.c.
. LU - CE RTI PI COMP P(EXEMPTION FROM WORKIiRS' ✓)
W > COd riot be coo INSURANCE PLG.CONTR. LIC.NO. PLG. `lr , O Y❑ N❑ Y ❑ ❑
Z (This section need not be completed if the permit is for one TOTAL C/ N
hundred dollars(5100)or less)
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mit is issued,I shall not employ any person in any manner so as to
U w become subject to the Workers'Compensation Laws of Calilornia.
Date Applicant BUILDING
}.tail NOTICE TO APPLICANT: If,after making this Certificate of Fax. ALTER OR ADD TO MECH. 5.00
F Z Sermon,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 10AODC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 110 OWC.F.M.) 6.00 SEISMIC FEE
I hereby affirmthat there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of(he work for which this permit 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
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
V, information is correct. I agree to comply with all city and county PLUMBING
ordinances and slate laws relating to building construction, andBOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 aQQ
hereby ucalorme representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE BCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. _
Cupertino against liabilities,judgments, costs and cxpenxes which PERMIT ISSUANCE 10.00 CONST.TAX
may any way accrue against said City in duce of thegra U gofthispMECH.CONT. LIG NO.ii •nn r TOTALSib ueo pp moot/Con Fuc , ��•�
INSPECTOR COPY