8345 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENT[FI CATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
y ApOREss BUILDING-ELECTRICAL-PLUMBING-MECHANICAL AS Mekfi jAAII C1, 10 8345
OWNER PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
�J
PNO
rCiory NE ERacT Rs UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO
LIGHTING FIXTURES 10.00/1.00
.
CONTRACTOR'S _ PP LI AN
ES
4.00
aoGREss {
I st J PROrvE PANELS 10.00 DATE OF APPLICATION
ARCHITECI PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.N0.
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARC".ss ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
APPLICANT'S MOTORS SEE FEE SCH.
ADORES
SERVICE CHANGE 20.00
'. 00 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a v I hereby'affirm Ihat 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
vHi< m (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r y z Professions C e,and 1 license is in full fore-n of e'.
z o Licunsc Class hie.Numhar�_ El 0
L
r contractor
_i BUILDING PERMIT
aBE BE a OWNERBUILDERDECLARATION t
t v INFORMATION
K ;LL 1 hereby Bllinn that I em exempt from the Contractor's License MISC.- REFER TO ORD VALUATION $/FT.
HLLOQ Law Ole following reason.l$ec.7031.5,Ifusinessand Professions PERMIT ISSUANCE 1QQO..� p'e
Code:Any city or counly which requires a per fit to construct,alter, / O
QQ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO.IF ELEC. ^ // _
- DLL requires the applicant for such permit to file a signed statement that TOTAL OZ0 PERMIT TO
K
he is licensed pursuan(to the provisions of the Contractor's License
Hzi
Law(Chapter 9(commencing with Section 7000)of Division 3 of lire
E x o Business and Professions Code)or that he is exempt Iheretroln and QTY, PLUMBING PERMIT FEE ?aFAFl, r
BE the basis for the alleged exemption.Any violation of Section 703 LS 1 STORIES TYPE CONSTR.
LL ; m by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER (EA.) $,00
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees wish wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and'['a structure is not
intended or offered for sole(Sec. 7044, Bushux, and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code: The Contractors License Law docs nor apply to an owner of
property who builds or Improves Tureen,and who does such work FIXTURES-PER TRAP 5.00 SG.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
ments are not intended oroffered for sale.If.however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM-OVER 4 (EA) 200 /
builder will have the burden at Proving that lie did no[build or im - . . .
- p BUILDING USE
prove for purpose of sale.). INDUSTRUf,L WASTE INTER. 30.00 RES IND CON- PS Omer
❑ 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 Contractor's License Law does not apply
to ao owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contmctons)licensed Pursuant to SEWER-SAN V-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
O lam 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.
WORKS RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofconsent to self-insure, ZONING ENG.SITE N0.
Xor a certificate of Workers'Compen on Insurance,or a certified
copy't hervef(Sec.3800 Lab.C.). �
Policy NvrLQ2� x-._pany
Q ❑ Ccr((If__"d it...y is h am by funnshcJ. FIRESPRINK ENERGY T24
Z Z ❑ Certifi' cop is ed wuli the city inspection division. MISC.- REFER TO ORD.
O, Applicant Y ❑ N❑ Y ❑ N❑
Cr N/ CE RTIFICA1 OF Ii XENI ION FROM WORKERS' PERMIT ISSUANCE 1 PLOOVONE A.L.U.C.
L COMPF-NSATION INSURANCE PLG.CONTR. LIC.NO. PLG. ^ i� V[D1 N❑ V ❑ N❑
CL Z 1'I 'his section ,red ,at he completed if the permit is for one TOTAL
hundred dollars IS 100)or less.)
U O 1 certify that in Om performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued, I shall not employ any person in any manner so as to 0
O w become subject to the Workers'Compensation Laws of California.
EL Dmc Applicant ALTER OR ADD TO MECH. 5.00 BUILDING Q
-} Go NOTICE TO APPLICANT. If,alter making this Certificate of Ex-
F Z emplion,von 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=12-F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I brushy affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the 3097.performance
Cia Cjn< e of the work for which this permit is issued(Sec. MICROFILM
HEATING UNIT 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 d 6 dU
I certify that I have read IN,application and state h,a,tiro above VENTILATION FAN (SINGLE) 4.00 r1
information is corner. I agree to comply will,all ch,
anJ county PLUMBING
ordinances and stale laws relating to building construction, and BOILER-CO MP(3 H.P.or100,000B.T.U.) 6.00 r
hereby authorize representatives of this city lc enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above mentioned property for inspection purposes.
(We) agree to east, indemnify and keep h.unds s the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10 0., i CONST.TAX
may in any way accrue against said City in consequence of the
granting of this permit. MECH.CONT. LIC.N0. MECH.
_ TOTAL TOTAL
� Si tore M plicartl0imuractor Date /
INSPECTOR COPY