8724 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
PERMIT BUILDINGNUMBER
APPLICATION & PERMIT
AUosAnil" 8 7 Z 4-
l�
ADDRESS
r e(�,
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
F
DavNE.' y PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
ONE
-` GAMER c o OUTLETS-SWITCHES-RECEP 10.00/1.00
_ uc.NO. 41 LIGHTING FIXTURES 10.00/1.00
co HATOR �I 16 APPLIANCES-RESIDENTIAL 4.00
ADDRESS
/^J• PHONE4jo PANELS 10.O
CHITECT
O DATE OF APPLICATION
A
oR �. LQA>r PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.N0.
ENGINEER
LIC.No. SIGNS TRANS. 3.00 (:{
AARC F,OR DDRESS ENG. SPECIALCIRCUIT 5,00 PERMIT VALIDATION
ZIP EMP.METER OR.POLE INS. 20.00
APPLICANT'S
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
w o O LICENSED CONTRACTORS DECLARATION' TEMP.POLE 30.00
a v I hereby off rah that I am licensed under provisions of Chapter 9 _ ISSUANCE DATE
(c(nnmencing will,Section 70001 of Division 3 of the Business and
Ci a vAi BLDG. E EC PLG. MECH.
H D z Professions Code,and my license is in full force nil effect.
z O w- License Class- Lic.Number*�y�B�
o m H Date Contractor
a Y BU LD NG PERMIT
¢ ¢ ¢ OWNER-Ii UILDfiR D[CLARA'I'ION
S,
w U NFORMATION
w ; 0 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
LL o a Law for the following reason.(Sec]031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION SIFT.
Ewi
f Code:Any city or county which requires a permit to construct,alter,
¢ ¢ a O improve,demolish,or repair any structure,prior to Its issuance,also ELEC.CONTR. LIC.N0. ELEC.
no
w m¢ ,requires the applicant for such permit to file a signed statement that TOTAL P MIT TO
he is licensed pursuant to the provisions of the Contractor's License
F z i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe -
a Business and Professions Code)or that he is exempt Omrefrom and QTY- PLUMBING PERMIT FEE
¢ r o the basis for the alleged exemption.Any violation of'Section 7031.5 STOR PE COrvSTR.
i ; m by any applicant fora permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(8500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCG 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,AR EA,COND. 5.00
Code:'The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTALACREAGE
• himself or through his own employees,provided that such improve-
menus are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-l1NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 IEA) 200
builder will have the burden of proving that he did not build or{m. - . - . . BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 RES IND N PB Other
❑ 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 ASSESSOR RCEL NO.
and Professions Code:The Contractor's License Law docs not apply
to an owner of properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts for such projects with a contmetolis)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ftf10.00 TRACT NO. PARCELNO.
❑ l am exempt under Sec.-,B&P,C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK 17 RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby ufdnn that 1 have a certificate of consent to self-insure. ZONING ENC.SITE NO.i
or a certificate of Workers Compensation Insurance or a certified
copy Iber f(Se L,3800 Lab.C.). .11
Policy N�ELhlfx(Ially , .�
0 C) Ce FitPo copy is ereby l'u the FIRE SPRINK ENERGY T 24
_Z Z _G1-Certiie cup is Bled wi01 the cit inspection division. MISC.- REFER TO ORD.
O PPlcam Y N Y ❑ NE]
LU
W y- CERTIFICATE OF EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 .L
FLOOD ZONE A .U.C.
W > COMPCNSATIOh'INSNSURANCE PLG.CONTR. LIC.rv0. PLG.
0 (P
' his section need not be.completed if the permit is for one TOTAL YE] N Y E] NE]
hundred dollars(S I o0)or lass.)
U O 1 certify that in the performance of the work for which this per. OTY. MECHANICAL PERMIT FEE FEE SUMMARY
W I- mil is issued,I shall not employ any person in any manner so as to
Ow become subject to the Workers'Compensation Laws of California.
Date Applicant BUILDING
} tai) NOTICE TO APPLICANT': It,after making Oris Certificate of Ex- ALTER OR ADD TO MECH. 5.00
� Z anption,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=CF,M) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE
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 H EATI N G U N IT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify ohm l have read this application 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 state laws relating to building construction. and BOILER-ODMP(3 H.P.Or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon tire BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
ahove-mentioned property for inspection purposes.
(We) agree to s.ve,.ird,mmTy 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
g ling orim permit. MECH.CONT. LIC.NO. MECH.
>C _ TOTAL TOTAL
n
g h DI Or at
INSPECTOR COPY