8388 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
eDO1Nc 1-49,C7' APPLICATION & PERMIT �x
ADDDRESS `Vn)
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
1 NAME CITY. ELECTRIC PERMIT FEE
NAMEA RS UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO. �- LIGHTING FIXTURES 10.00/1.00 C .-
CONTRACTOR'S / PPLIANCES-RESIDENTIAL 4.00 i
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE D.C.N0.
OR
O
ENGIN EER
uc.NO. SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00
ZIP EMP.MET- R OR POLE INS. 20.00
A . { t
ADDRESS MOTORS SEE FEE SCHSS J
SERVICE C ANGE 20.00
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 D
< v u 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
uHi a N (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F wz Professions Code,and my license is in full force and effect.
z 0 w - LicenseClass Lia Number u 7
El0 z F o Date Contractor
a r E I BUILDING PERMIT
w u OWNER-BUILDER DECLARATION INFORMATION
E:
0a H re
I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD {
3 u ut VALUATION S/FT.
H .. O j Law for the following reason.(Sec 7031.5,Business and Professions PERMIT ISSUANCE 10.-00
Code:Any cityor county which requires a permit to construct,2lteq
Qp Q Q improve,demolish,or repair any structure,prior to Its Issuance,also ELEC.CONTR. LIC.NO. ]ELEC.
A m u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
u w ua
he is licensed pursnt m the provisions of Li
the Contractor's cense
P. z i Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe r
- a Business and Professions Code)or that he isexempt therefrom and CITY. PLUMBING PERMIT FEE
r o the basis for the alleged exemption.Any violation of Section 7031.5 SYOFrIES TYPE CONSTR.
dam _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ 1,as owner of Ore property,or my employees 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 Cor solo(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 5.09 SQ FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employers,provided that such improve-
ments at, not intended or offered for tile.If,however,the building GAS-EA.SYSTEM-11INC.4 OUTLETS 6.00
r improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving That he did not build or int- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 1,as owner of the property,am 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 Code:The 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 for such projects with a contractorts)licensed pursuant to SEWER-SANITAR V-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-.BAP.C.for this WATER HEATER W/VENT 6.00
eason
Owner - Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
wORKISRs'COMPIiNsn1'ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby afftrn that I have a certificate ofconsent to self-iosure' ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a terrified
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby famished- FIRE SPRINK ENERGY 24
Z Z ❑ Certified copy is filed with the city inspection division.
O Applicant MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N❑
N CERT1FICA'I F 017 EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LL > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL y 11 N El Y 1:1 N 1:1O (This section need not be completed if the permit is for one TOTAL
ZD Z hundred dollars(S 100)or less.)
U O 1 certify that in the performance of the work for which this per, CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,1 shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
W Uam Applicaml ALTER OR ADD TO MECH. 5.00 BUILDING a.�
>_ to NOTICE '
'f0 AITLICANf: 1f,after nicking this Certificate of Ex- -
♦- Z• emption,you should become subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK K<
provisions of the Labor Code, you [Trust forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE S Q
I hereby affirm 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's Address HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC / (h
I certify that l have read this application and state that Ore above VENTILATION FAN (SINGLE) 4.00
. informmion is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to hudding on on, anA BOILER-COMP(3 H.P.or 100,000B.T.U.) 6.00
hereby authorirc representatives of this city to enter upon the BO' ER (Over 100,000 BTU)SEE FEE SCM. 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 in any way accrue against Said City in consequence of the
panting Of This permit. MECH.CONT. LIG N0. MECH.
`f� ( / y_ � DIAL TOTAL 3�<Sa
�fJ 1I I t D(f/ i-
INSPECTOR COPY