8566 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
ADAPPLICATION & PERMIT
oBESS 8566�^^
8egBUILDING-ELECTRICAL-PLUMBING -MECHANICAL
NAME 'a PLAN CHECK VALIDATION
• OTY. ELECTRIC PERMIT FEE
PHONE 1
NAMT s
A
EUTLETS-SWITCHES-RECEP 10.00/1.00
7 UC.NO. C LIGHTING FIXTURES 10.00/1.00
j .o TRA oR
ADDRESS APPLIANCES-RESIDENTIAL 4.00
HONE 4. �� PANELS 10.00 DATE OF APPLICATION
' ORC IT C PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
11C.NO SIGNS TRANS. 3.00 'l
ARCH.OR ENG. PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00
ZIP EMP.METER OR POLE INS. 20.00
AADDDRRSSESSCANMOTORS SEE FEE SCH. n ,
SERVICE CHANGE 20.00
j o a LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 /�S` /!✓
E < v w I hereby afore that I am licensed under provisions of Chapter 9 ISSUANCE DATED l
y<z (Commencing with Section 7000)of Division 3 Of the Business Rod BLDG. ELECT. PLG. MECH.
F D z Professions Code,and my license is in full force and effec /
( z o w - License Class_!�.(�_Lir.Number
Q !7r w Date l Contractor a
H _ J
BUILDING PERMIT
a ¢ a OWNER-BUILDER DECLARATION
A o a u INFORMATION
w LL I hereby affirm that I a.n exempt bone the Comractor's License MISC.- REFER TO ORD
LLoa Law for the following rcusnn.IScc.7031.5,Busincssand l'rofcssions PERMIT ISSUANCE 10.00 VALUATION $/FT.
� - Coda:Any city or county which replires it permit to construct,after,
K ¢ 0 improve,demolish,or repair any structure,Prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
C ¢ requires the applicant fm such permit to lite n signed sWlenua t that TOTAL PERMIT TO
w m he is licensed Pur..out to the provisions Cl the Contractor i license
F z i
Law(Chapter9(commencie,with Section 7000)01Division 3of the _
P o Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE L
¢ r ro the basis for tem alleged exemption.Any viotmion of-Section 7031.5 STORIES TYPE CONSTR.
a g -. by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(S5000.):
❑ 1,as owner of the property,or my employres with wages as BACK F LOW PROTECT.DEV ICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do 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 does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such'a'Prove-
ments are not intended or offered for sale.11,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM-OVER 4 (EA) 200
builder will have the burden of proving that h - . . .
e did not build or im- BUILDING USE
prove for r ll(of roRES IND CON PB Other
C) as owner
le.). INDUSTRIAL WASTE INTER. 30.00 E] El ❑ El 1:1' I.as owner of the properly.aexclusively 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 Code:The Contractor's License Law docs 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 SEWER-SANITARY-STORM EA.200ft/10.00
Ill,Contractors License Law. TRACT NO. PARCEL NO.
D lam exempt under Sec.-.BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I leave a eertit irate of consent m self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(See 3800,Lab C.)
Policy Nb4,1"& omPany
O ❑ CCrtltled cO hereby lurmshed. FIRE SPRINK ENERGY T 24
Z Z P�Ce rotted copy is filed with the city inspection division.
FO A nt I&e006,_T��BA` _PI1`���)a MISC- REFER TO ORD. Y ❑ N❑ Y N❑
= N CERTIPICATI'OP EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG,
O (This section need not he completed il' the Permit is for one TOTAL Y[:] N❑ Y ❑ N❑
Z hundred dollars($100)or less.)
U O 1 cC,tily that in the pe bomance of the work]or which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mil is Issued,I shall not employ any parson in any meaner so as to
U become subject en the Workers'CunlpCBmtion Laws of California.
W Date ApplicantBUILDING
m NONCE '10 APPLICANT': 11,after eed,mg this Certificate of fix ALTER OR ADD TO MECH. 5.00
� Z cmplion,you should beconw subject to Dec 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 decried revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONS TRUCPION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000O.F.M.) 6.00 SEISMIC FEE
I hereby Infirm 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(Sec MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender y Address HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I Certify that I have read this ap,licatim,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 rate laws relating to building construction, and BOILER-COMPI3 H.P.or100,000B.T.U.) 6.00
hereby authorize representatives of this City H eater upon the BOILER-COMP (Over 100.000 BTU)SEE FEE SCH. MECHANICAL 0-W
above mentioned property for inspection purposes.
(we) agreem 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 in any way (cane against mid City in consequence of the
granlin oflhis permit. MECH.C.ONT. LIC.NO. MECH. J
_ QG/ TOTAL (� TOTAL
Signature o ppmanl/Co Ir r Date e d r VO
INSPECTOR COPY
s