C8657 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
f/ BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
/^` Be LDING APPLICATION & PERMIT 857
ADORESs Cl b
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 6
OW PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
A Hq PNONE
NA RA ro 's UTLETS-SWITCHES-RECEP 10.00/1.00
AME
I - LIC.NO. l S c r LIGHTING FIXTURES 10.00/1.00
roNrancToas PPLI ANCES-RESIDENTIAL 4.00
AD DR
7 veorvE _ PANELS 10.00 DATE OF APPLICATION
` \�^ ORRCart CT �& bY6 PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P,C.NO.
ENGINEEa �+
LIC.No SIGNS TRANS. 3.00
nooREss ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
zip ? EMP.METER OR POLE INS. 20.00
• ASMOTORS SEE FEE SCH. J
ADDDREORESSS
¢¢¢ SERVICE CHANGE 20.00
LICIiNSED CONTRACTORS DfiCL,\RATI N TEMP.POLE 30.00 3/ 4in
a U I herebyaffirm [],at I am licensed under provisions of Chaptc,9 ISSUANCE DATE
:.y
(commencing with Section 7000)of Division 3 of the Business and =0$ E LG. MECH.
r�iy z Professions Code,and my licensers in full force and effect.
Z 0.m - License Cluss��� Lit.Number ❑
g ps. Data-�-./ -� CDNrec or
m s " ' T ` BUILDING PERMIT
w ¢ OWNER-BUILDER DECLAR ON
U INFORMATION
AOA MISC.- REFER TO ORD
X 3 u- N I hereby affirm that I am exempt from tic Contractor's License VALUATION $/FT.
Hu0J Law for the(ollowing rcasom(SeC.7031.5,Businessand Professions PERMIT ISSUANCE 10.00
Code:Any city or county which r,gei,r,a permit toconstruc[,alteq •/•
oimprove,denwllsh,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC,NO, ELEC.
ca O¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT Tp.
n w m u- he is licensed pursuant to the provisions of the Contractors License (i//
Fri Law(Chapter 9(commenciagwith Section 7000)o(Division 3 of the
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
r c Vw 19
the basis for the alleged exemption.Any violation of Section 7031.5 DRIES TYPE CONSTR.
d ; w by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not..lore than five hundred dollars(8500).):
❑ I,as owner ol'the property,or niy employees with wages as BACK FLOW PROTECT. DEVICE 4.00 DCC.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:'IIIc 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 So.FT rLOOR AREA TOTAL ACREAGE
himselfor through his own employees,provided that such improve-
mentsarenotintended or offered for sal,if,however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00
or improvement is sold,wi[hin one year of completion,tire owner- GAS-EASYSTEM-OVER 4(EA) 200 BUILDING USE
builder will have the burden of proving that he did not build Or im . . .
RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
Iieemsed contractors m 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 does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 I
contracts for such projects with a contracons)licensed pursuant to SEW ER-SANITARY-STORM EA.200ftI10.00
the Contractor's License Law, TRACT NO, PARCEL NO.
❑ I;unexemptunder See, .B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
/I WORK[,RS'COM PENSATION DECLARATION WATER TREATING EQUIP. 5.00
//,{`' I hereby affirm that I Imve a certificate of consent to set Ginsum, ZONING ENG.SITE NO.
or a certificate of Workers Compensation Insurance,or a certified
copy thereof(Sec.3800,Iab.C.I
Policy No.p,--(q>{ompuny- p-!(
O ❑ CerUli' ed cop)'is hereby furnished. FIRE SPRINK ENERGY T-24
z Z ❑ Certified copy is fled with the city inspection division. MISC.- REFER TO ORD.
O Applicant ��,�G`` Y ❑ N❑ v ❑ N❑
r � PERMIT ISSUANCE - 10.00 FLOOD ZONE A.L.U.C.
Lu N ` CI: TIIY 'COM(lESAIIOT INS PROM WORKERS'
W 7 COd ,.I A'I'com INSURANCE - PLG.CONTR. LIC NO. PLG. Y❑ N❑ Y ❑ N❑
d (This section need ren be completed if the permit is I'or one TOTAL
Z hundred dollar(5100)or Icss.) -
U O 1 certify that in the performance of the work for which this per- OTY. V MECHANICAL PERMIT FEE FEE SUMMARY
LL
H mit is issued.I shall not employ any person in any manner so as to
at tiecome subject to the Wlicant 'Compenwtian Laws of California. BUILDING �l
U y Datc Applicant ALTER OR ADD TO MECH. 5.00 S C�
} m NOTICE '10 APPLICANT: If,after making Ihis Certificate of Ex-
f- ? eruption,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 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that.there is a consonction lending agency (or 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
Lenders Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have.read this application and state that the above VENTILATION FAN (SINGLE) 4.00
onform drdinanceso correct. I agree to comply with all city and county PLUMBING
iand stale laws relating 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 BOILER-COMP IOver 100,000BTUISEE 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 CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
gonlingol'this permit. MECH.CONT, LIC.NO,
a [ anMECH.
I� TOTAL TOTAL / �h
a o ppbctra or Da "1
INSPECTOR COPY
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