C8453 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIF I CATION PERMITNUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
7 __g,g0Jq1 Cue I BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
OWNERS -PLAN CHECK VALIDATION
E
\7l/ N QTY. ELECTRIC PERMIT FEE
(fQ 0Al2PHONE -
E
o s OUTLETS-SWITCHES-RECEP 10.00!1.00
-
LIC.NO, LIGHTING FIXTURES 10.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC./NO. SIGNS TRANS. 3.00
ARCH
ESS ENc. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
AMOTORS SEE FEE SCH:
DRESS E55
ADOR 5
SERVICE CHANGE 20.00 a[
0 0 o LICENSED C'ON'TRACTORS DECLARATION TEMP.POLE 30.00 1k/4>Z //�s'-
¢ W u I hereby affirm that 1 sen licensed under provisions of Chapter 9 ISSUANCE DATE
na H (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H w z Professions COde,and my license is in full force and effect. ❑ ❑ ❑ ❑
z o,.I - License Class Lia Number
9 z Date Contractor
yH
a m - BUILDING PERMIT
¢ ¢ w ¢ OWNER-BUILDER DECLAIdA'I'ION INFORMATION
o n o MISC.- REFER TO ORD
U- y I hereby affirm that I am exempt from llc Contractor's License 'VALUATION_ $/FT.
H .. o j Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 Gt.J
Code:Any city or County which m9 uims a permit to construct,ulteq �/�p ,I
¢ ¢ Q Q improve,demolish,or tcpair any Sur¢lure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC: .✓ /(Jz
- O ¢ requires the applicant for such permit to fill:a signed statement that " TOTAL PERMIT TO
Is m he is licensed pursuant to the provisions of the Contractor's License
seLaw(Chapter 9(commencing with Section 7000)of Division 36[flic 1•Y f/RC�L•�.G�
sr Business and Professions Code)of that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r c the basis for the alleged exemption Any violation of Section 7031.5 - STORIES TYPE CONSTR.
nam by any opplicum fora pennit.aubjeas 0fe'upplice�nl0.ia civil penalty gLTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars(5500).1: I
❑ I,as owner of the property,or my employees with wages as; BACK FLOW PROTECT. DEVICE 4.00 OCC. RES.UNITS
their sole compensation,will do the work,and the structure is not, . 1
intended or offered for sale (Sec. 7044, Business and Professions' DRAINS-FLOOR,ROOF,AREA,COND. 5.00 r }
Code:The Contractor's License Law does not apply to an owner of l 1
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP IT 5.00 SO.FT.FLOOR AREA TOTALACREAGE
nwritslare not
oon ffered orsle.11,,d that howelvsueh imildin GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
mems are mol intended or offered for sale.If,mpleveq 0(h budding
or improvement is sold within one year of completion,the owner-
builder
wner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
but Wer will have the burden of proving that he did not build or int- BUILDING USE
prove for purpose of snlcJ. INDUSTRIALWASTE INTER. 30.00 RES IND CON PB Omar
[1I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors t0 construct the project(See. 7044,Business- LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 L ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does mH apply 1
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 contracioHs)licensed pursuant to •SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. ' TRACT NO. PARCEL NO.
❑ .I oro exempt I..."See. ',If.&PL.for this ,� WATER HEATER W/VENT 6.00
'as'sa x
Owner Uute r - WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPEN'l, ON DE:CLARA'I'ION( WATER TREATING EQUIP. 5.00
I hereby affirm.lhm I have a certificate of consent to sell'-insure, ZONING
or a certificate of-Workers'Compensation Insurumo
e, r a certified ENG.SITE N0.
copy themoff&ec.3900,I-A.CJ. .�.-✓
Policy No. - Company ,q
O ❑ Certified Copy is hereby,furnished. FIRE SPRINK ENERGY;Y]4'
Z Z ❑ Certified copy is filed with/the city inspection division.
O Applicant MISC.- 'REFER TO ORD, Y❑ N❑ v'❑ N❑
CCN CF,RTIFICA'I'E OF EXF.MPTIONXROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONEr. A.L.0 C.
LL > COMPENSATION INSURANCE PLG.CONTR. LIC.NO: PLG. ❑ ❑ [:] ❑
(I his section need not completed if the permit is for one TOTAL Y N Y N
hundred Aollurs(E 100]or Icssy)11
U 0 1 certify (bat in the performance of the work for which this per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,1 shall not-employ any person in any manner so as to
U' become subject to the Workers'Compensation Laws of California.
0. Date /ApplicantALTER OR ADD TO MECH500 BUILDING /3 rn
- rn NOTICE TO APPLICANT': If,alter making this Certificate of Ex-
. .
F Z emption,you should,become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK S-
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=C.F.NL) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that Thera is a c nistructimi lending agency for EXHAUST HOOD(WITH DUCT) 5.00 _, -
,the performance: of the work for which thiz permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name / 0+''HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC sit
Lender's Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
O information is correct. I agree to comply with all city and county PLUMBING
ordinances and stale laws relating to building construction. and BOILER-OOMP(3H.P.or 100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. gO1LER-COMP IOver 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
g cling of this permit -al
MECH.CONT. LIC.NO. MECH.
V414�16 TOTAL TOTAL %S
$i61t plical n r c at
UP INSPECTOR COPY It
,) I