8200 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT 1 DENTI FICATI ON PERMIT NUMBER
ADDRESS APPLICATION & PERMIT ���
BUILDING
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
R PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
ONE
NAMERAcrons / UTLETS-SWITCHES-RECEP 10.00/1.00
uc,NO 7rfn LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
ADDRESS PPLIANCES-RESIDENTIAL 4.00
'
PHONE ' p PANELS 10.00 DATE OF APPLICATION
opcesecr 11 C - PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE PIC.NO.
ENGINEER
uc.NO SIGNS TRANS. 3.00
ADDRESS ENG. PERMIT CIRCUIT 5.00 PERMIT VALIDATION
zIP TEMP.METER OR POLE INS. 20.00
APPLI C ANTSMOTORS SEE FEE SCH.
DRESS
ADDIi ESs
SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 '
<it u I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
a, <w (commencing with Section 7000)of Division 3 of the Businessand B 00. ELECT. PLG. MECH.
H'N z Professions Code,and vty license is in full force and effect. ❑ ❑ ❑
i'O w - License Class Lic.Number ,
o m- Date Contractor
H
a a E JA BUILDING PERMIT,
¢ ¢ < OWNER-BUILDER DECLARATION
0 0
.X 3 n m I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION 3/FT.
LL O a Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 10.00
fw Code:Any cityorcounty which requires a permit to construct,alter,
¢
improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO.
¢ ¢ O ELEC. U
au
O LL requires the applicant for such permit to file a signed statement that TOTAL PER MITTO
isLa $ he is licensed pursuant to the provisions ol'the Contractors License
Law(Chapter 9(commenciag with Section 7000)of Division 3 ofthe
< Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ F o the basis for the alleged exemption.Any violation of Section 7031.5 IS MNIE9h vPE CONSTR.
A ;m by any applicant for a permit subjects the applicant to a civil penally
of not more than five hundred dollars(S500).): ALTER-DRAIN& VENT-WATER (EA.) 5.00
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 DEC.CROUP Res.urvtTS
their sole compensation,will do the work,and the structum is not
imtcRiled 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 SO.FT FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00 '
.. ments are not intended or offered for sale.If,however,the building
or improvement is sold within one year 01 completion,the owner- GAS-EASYSTEM-OVER 4(EA) 200 BUILDING USE
builder will have the burden of proving thin h . . .
u did not build or HR. R B IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER3000
❑ 1,as owner of the properly,am exclusively contracting with . .
❑ ❑ ❑ ❑
licensed contractors no construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code: The Con(ractor'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 conlraOORs)licensed pursuant to SEWER-SANITAR V-STORM EA.200ftI10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec B.SPC.for Dlis WATER HEATER W/VENT 6.00
reason
Owncr Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent ro self-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.CA
Policy No. Company
C5 ❑ Cetlilied copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z C) ❑ Cerificd s fled wn the city inspection division.
O f
Applicant I -- MISC.- REFER TO ORD. Y❑ No v ❑ No
-.� P � po sy
~ m PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU GISk'1'1 PICC0 OP I AX I N IFROM WORKERS'
W need not be co N INSURANCE PLG.CONTR. LIC.NO. PLG. Y❑ N❑ Y ❑ N❑
CL O hundred
dollars S10 or be completed if the Dermic is for one TOTAL
D Z hundmd dollars f5100)or less)
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL h- mit is issued,I shall not employ any person in any manner so as to
Q become subject to the Workers'Compensation Laws of California.
y Date Apphcamt ALTER OR ADD TO MECH. 5.00 BUILDING 0�
} w NOTICE '1'0 APPLICANT': If.alter making this Certificate of Es-
you
F Z eruption, should bernme subject to the Workeri'Compens:dion 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.NL) 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(Sea MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's
Lender's AAddrddoeHEATING UNIT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
ss
I certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
e information is-correct.I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTUI SEE FEE SCH. MECHANICAL
above-nwntioned property for inspectirn purposes.
(We) agree to save, indevnnify and keep Imnn less the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
grantingofthispermit MECH.CONT. LIC.NO. MECH.
/1_ - ,�,ryy�� - a^p� TOTAL TOTAL
81'g ? 'A�h�ontmcCC 'tor Date /1 to,
INSPECTOR COPY