8334 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
BU LDING-ELECTRICAL-PLUMBING-MECHANICAL 8334
R' PLAN CHECK VALIDATION
7 NAME OTY. ELECTRIC PERMIT FEE
I PHONE All
NAMhERACTDns UTLETS-SWITCHES-RECEP 10.00/1.00
f _ LIGHTING FIXTURES 10.00/1.00
� 0.N0.
raDRESS R's PPLIANCES-RESIDENTIAL 4.00
� ADDRESS
T" t
? PHONE _ PANELS 10.00 DATE OF APPLICATION
OR Hrt cT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE PC.NO.
ENGINEER
LIC.No, SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
znR TEMP.METER OR POLE INS. 20.00
APPLICANT MOTORS SEE FEE SCH. 5
ADDREars ss
SERVICE CHANGE 20.00
0 o O LICENSE])CONTRACTORS DECLARATION TEMP,POLE 30.00
< U I hereby affirm that I am licensed under provisions or Chupt'er') ISSUANCE DATE
,Hn n (connnencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H N i Professions Code,and my license is in full force and effect. ❑ ❑ ❑ ❑
z o m - License ClassS�,{eNS,, .Lie Number '}f a
Date Contractor T4.,q¢�n .*z.,
a r E 3 �S TT 1m TC caVT,EOt_ BUILDING PERMIT
K ¢ OWNER-BUILDER DECLA A M -
o d U INFORMATION
X 3 n r 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
to
Law for the following reason.(Sec.7031.5,BisinessandProfcssions PERMIT ISSUANCE 10.00 VALUATION $/FT.
Code:Any city or county which requiRS.permit tocon Unct.mter, q
Q ¢ Q p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
d w- O u requires the applicant for such permit to file a signed statement that TOTgL PERMIT TO
m he is licensed jamouanl to the provisions of the Contractor's License
H z i Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe jJ�
a Business and Professions Code)or that he is exempt therefrom and QTY, PLUMBING PERMIT FEE ,(,T91 0 UH 'l� •'.D
f o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
A. by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars 145001.1:
❑ 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 the work,and the structure G 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 improve
..is are not intended or offered for sale.If.however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 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 he did not build or ice - . . .
- BUILDING USE
Prove for purpose of sale.). RES IND CON PS Other
❑ 1,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00El El El 0 El
licensed eoCtNcton to construct the project(Sec.7044,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 ASSESSORS lARCEL NO.
sad Professions Code:Tire Contractors 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 fur sot'II projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I em exempt under Sec I BAP C.for this WATER HEATER W/VENT 6.00
reason
Owner Date - WATER SYSTEM 5.00 Act.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate otconscut to sell-insure' ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certifwd
copy lhereof(See.3800,Lab.C I ZACK. NcAL41NS<p2idy,T\ -
Policy No, Company I v) -♦
U ❑ Certified copy is hereby fu rmshed.
FIRE SPRINK ENERGY T 2
z Z ❑ Certified copy is Bled with the city inspection division.
OT Applicant��f,�a�-� e, MISC- REFER TO ORD. Y E) No Y E) NE]
~ vl PERMIT ISSUANCE 10.00
LU CERTI PICCOI OP EXEMPTION FROM WORKERS' FLOOD ZONE A.L.U.C.
W ? COMI'P.t be eON INSURANCE it 11o, vLG.CONTR. LIG NO. PIG. YE] NE] Y [] N�
2 (This dollars need not he conhpleted if Ibe permit is for ane TOTAL
hundred dollars 1 n (lie Pe less.)
U O 1 certify that h the performance of ifs work]or which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
0 Q bee is issued.I shall not employ any ersaon in any ma Calif so is to
become subject to tl¢Workers'Compensation Laws of California.
Date A hcanl BUILDING
} N NOTICE TO APPLICANT: If,after making this Cerlificam of Ex- ALTER OR ADD TO MECH. 5,00
F Z
tropical.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 Inelt provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10X0C.F.M.) 4.00
CONS'fRUC'1'ION LENDING,AGENCY AIR HANDLING UNIT(OVER 10)DOOC.F.M.) 6.00 SEISMIC FEE S"7J
I hereby affirm that there is a construction lending agency lir E? UST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sea. MICROFILM
3097,Civ.CJ. HEATI G UNIT(TO 100,000 B.T.U.) 8.00
Lenders Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that l have read this application and srate that the above VENTILATION FAN (SINGLE) 4.00
information is correct I agree to comply with all City and county - PLUMBING
ordinances and stale laws relating IT, building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
lo,ohy aolluniru rcprescntwrvcs of this city to enter upon The
above-mnnlioned property for inspection purposes. BAILER-COMP(Over 100,000 BTUI SEE FEE SCH. MECHANICAL
(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 in any way accrue against said City in consequence of the
granting of this permit oMECH.CONT. LIC.NO. MECH.
..�J 011 /r, - TOTAL TOTAL �i 6FJ
$ugnalureo Applicant/Contractor ate
INSPECTOR COPY