8356 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILD, G
DDRESAPPLICATION & PERMIT ^��
? ADOREss L e{
i/ BUILDING-ELECTRICAL-PLUMBING-MECHANICAL lT
WNE PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
6rnaPNONE
1UNT ACTOR UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
LIC.NO. LIGHTING FIXTURES 10.00/1.00
DEAcrOFs
ADDRESS APPLIANCES-RESIDENTIAL 4.00
AD
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
0.ENGINEER
uc.NO SIGNS TRANS. 3.00
ADDRESS ENG. PERMIT 5.00 PERMIT VALIOgTION
ZIP EMP.METER OR POLE INS. 20.00
ADDRESScss MOTORS SEE FEE SCH. �„J
ADDR
SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a u 1 hereby affu m that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
yz "' (commencing with Section 7000)of Division 3 of the Business and
Q y BLDG. ELECT. PLG. MECH.
F v,z Professions Code,and my license is in full force mW effect ❑ ❑ ❑ ❑
z m - License Class Lia Number
Oz 2 v, , Date Contractor
`a m ISBUILDING PERMIT
IS OWNER-BUILDER DECLARATION
E. o a uINFORMATION
X ; ,� H I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
LL o J Law for the following reason.(Sec.7031.5,Business and Professions pERM1T ISSUANCE 10.00 VALUATION
Ew�E Code:Any city.,county which requires apermil l.construct,alter,
¢ ¢ Q O improve,demolish.or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
D¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
E
he is licensed pursuant to the provisions of the Contractor's License
Hzi Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe J1��
< Business and Professions Code)or that he is exempt Iherefrom and DTV. PLUMBING PERMIT FEE
i D
¢ r o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
u3 � by any applicant for a permit subjects the applicant ma civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars($500).)
❑ 1,as owner of the property,or my anployees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC,GROUP RES.UNITS
their sole compensation,will do lite work,and the structure is 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 docs such work FIXTURES-PER TRAP 5.00 So.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve.
.cuts are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM 1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of pruvmg that he did not build or un. BUILDING USE
more for purpose It cJ. INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(See.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
contracts for such projects with a contractor(s)licensed pursuano to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ I am exempt under S c. ,B.&PC.for this WATER HEATER W/VENT 6.00
reason
Owner Duce WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORRIS 'COMPEN ATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure. ZONINGor x certificate of Workers Compensation Insurance,or a certitied ENG.SITE NO.
copy thercof(Sec.3B00,Lab.C).
Policy No. - Company
O ❑ Certified copy is hereby furnished. FIRESPRINK ENERGY T 24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O ApplicantY ❑ N❑ Y ❑ N❑
CC CERTIFICAI IT OFEXEMPTION('ROM WORK ERS' PERMIT ISSUANCE 1Q•00_ �-� FLOOD ZONE AT.0 C.
LU > COh PENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL 0 (This section need not be conipletutl if the permit is for one TOTAL / 0 fJ V❑ N Y ❑ N❑
::) Z hundred d.Ilms($100)or less)
U O 1 certify that in the performance.f the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in any manner so as to
O become subject to the Workc,,Compensation Laws of California.
Lu Date Applicant BUILDING
0.
} 0 NOTICE: 'f0 APPLICANT: If,after nuking this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
F ? coalition,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=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 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.). H EATING UN IT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all oily and county PLUMBING
oodinances and state laws relating to building construction, and BOILER-COMP(3H.P.or100,000B.T.U.) 6.00
hereby authorize representatives of this city In enmr upon the BOILER-COMP (Over 100,000 BTU(SEE 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 mW expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way acerae a• st saidCity consequence of lite
grant ti's permit MECH.CONT. LIC.NO. MECH,
TOTAL TOTAL
p / on tra Date
INSPECTOR COPY