C8415 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
i
I BUILDING PROJECT IDENTIFICATION PERMI NUMBER
' IWILDING APPLICATION & PERMIT '
PDaREss
/\ 6� _ / BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNE 'S PLAN CHECK VALIDATION
NAME
r QTV. ELECTRIC PERMIT FEE 14
3, WWI PHONE < - l
CONTRACTOR'S
NAM UTLETS-SWITCHES-RECEP 1 /1.001 r
r !- n _LIC.No. 7Z LIGHTING FIXTURES 0/1.00 <-
'114111
-/
r. NTP Rs PPLIANCES-RESIDENTIAL 4.00
POOREs A
Al NE 9 PANELS IO.00 DATE OF APPLICATION
ARCHITECTon PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P,C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
moo ESS ENc, SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
i
ZIP EMP.METER OR POLE INS. 20.00
T /��
APPLE CANS
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
w 0 o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
Q u I hereby if inn But 1 ant Ii ceased under provisions of Chapter 9 ISSUANCE DATE
w (commencing with Section 7000)of Division 3 of the Business and
8 D E EC PLG.- MEC
F w i cenA,Cla Code, d my license is in full force and-feet
z O m - License Clus Lic.Number ! "
`O mDateContmdor_
r
a x BUILDING PE MIT
m a w D OWNER-BUILDER DE C• INFORMATION
w ;A,y I hereby affiRn that I ant exempt from the Contractor's Lice s MISC.- REFER TO ORD
u O j Law for the following reason.(Sec.7031.5,Business and Professions VALUATION $/FT.
- PERMIT ISSUANCE 1
is
EwCode:Any city or county which requires a permit to construct,alter.
re Q Q O improve,demolish.or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
D tt requires the applicant for such permit to file a signed statement that TOTAL PE M
he is licensed pursuant to the provisions of the Contractor's License
F z r Law(Chapter 9 tcommencing with Section 7000)of Division 3 ofthe
Q Business and Professions Code)or that he is exempt therefrom and QTV. PLUMBING PERMIT FEE
r m Ore basis for the alleged exemption,Any violhu mn of Suction 7031.5 t O Tv CONSTR,
d32by any applicant for a perm it subjects the applicant toe civil penalty ALTER-DRAIN -WATER (EA.) 5.00 '>'
of not more than five hundred dollars($500).):
❑ 1.as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for ale(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 4V
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 In'
prove-
meats are not intended or offered for sale.IL however.the building GAS-EA.SYSTEM-I 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 proving that he did not build or int- BUILDING USE
R 5 IND CON PB Other
prove fors owner of the.l. INDUSTRIAL WASTE INTER. 30.00
❑ L as owner of the property.ire exclusively contracting with 0 0 0 0
licensed contractors to construct the project(See. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORSPARCELNO.
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 contractods)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sea ,B.&P.C.for this
eason WATER HEATER W(VENT 6.00
r
Owns Dat' WATER SYSTEM 5.00
ACC.GATE ACG FILE NO.
WORK ERS'CONIPFNSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofmnsent in self-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof ISec.AO;Lab.C.f
Policy No. ompany
• 0 ❑ CSR Reck nis hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certifie o Y i% tiled wi DO' city inspc firm -'vis' n
FO Avplicanl MISC.- REFER TO ORD. - v [] NO V � N�
Cc: T CI4111f sICATE OF EXEMPTION 1:1611 WORKERS' - PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W > COMPIINSAT ION INSURANCE PLG.CONTR. LIC.NO. PLG. /
(T ❑ ❑ ❑ 1:1 his section need not be completed if the permit is for one TOTAL V N v N
Z hundred dollars IS 100)or less.)
Q O 1 certify that in the performance of the work 1'or which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
lL U mit is issued,I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} So NOTICI7 TO APPLICANT. If,after making this Certificate of
Ex-emption,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
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER IQOCOC.EM.) 6100 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 that I have read flits application and state that the above VENTILATION FAN (SINGLE) 4.00 '
• infonnution is correct. I agree to annply with all city and county BOILER-COMP(3 H.P.Or 700,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby anthmize r untatives of this city tr enter .von the gQILER-COMP(0ver 100,000 STU)SEE FEE SCH. MECHANICAL
above-mentioned o rty for inspection purposes.
(We) agree t saw , indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino agar' li ililies,judgments, co - and expenses which CONST.TAX
may in any y ecru, against said Ci n Consequence of the PERMIT ISSUANCE 10.00
granting fth' p mil. MECH.CONT. LIF NO. MECH. /
\ TOTAL TOTAL r/
i Sign' re f pbean/Contractor a e ' I
INSPECTOR COPY
5