C8338 A APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
AAPPLICATION & PERMIT
ADDDRESSDRESS it
i�
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
Ow E 'S LAN CHECK VALIDATION
NAME �]///V��Jp '/�r / t QTY. ELECTRIC PERMIT FEE
' PHONE O-/4✓-,<S3
NAMECONTOUTLETS OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC,No. LIGHTING FIXTURES 10.00/1.00
ADDRESS ORs PPLIANCES-RESIDENTIAL 4.00
CONTRACTOR
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE 77Nil
on PANELS (OVER 200 AMP) 20.00
ENGINEER
uc.No, SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5:00
ZIP EMP.METER OR POLE INS. 20.00
ADDRESS
ES
AMOTORS SEE FEE SCH. i
DR1
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
G v p I hereby affirm that I am licensed under provisions of Chapter! ISSUANCE DATE
(conunencin with Section 7000)of Division 3 of the Business and
a la g BLDG. ELECT. PLG. MECH.
f o i
Professions Code,and any license is in full force and effect ❑ ❑ ❑
a z= o License Class othroatier h
H y F J Date-COntmClOf
BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DECLARATION
MISC.- REFER TO ORD INFORMATION
X 3 LL I- I hereby affirm that I am exempt from the Contractor's License
¢ D sc Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
so Code:Any cay or county which requires a permit to construct,alter,
Qor¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEG CONTR. LIC.NO. ELEC.
o LL requires the applicant for such permit to file a signed statement that TOTAL - PERMIT TO
1 412
w m w be is licensed pursuant to the provisions of the Contractor's License
Hzso Law(Chapter9(commcncing with Scclien 70000olDivision 3 cfthe
a Business and Professions Code)or that he is exenmt therefrom and QTY. PLUMBING PERMIT FEE
E x o
¢ F p the basis for the alleged exemption.Any violation O($CClion 7031.5 STOFIIES TYPE CONSTR.
Ps' by any applicant for a permit subjects Ute applicant toa civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(5500)J:
❑ I,as owner of the property,or my employees will,wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP REB.UNITS
intended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 -
Code:The Contractor's License Law docs not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 5Q.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve.
meals 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 proving that he did not build or im BUILDING USE
.prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
C11,as owner of lire property,am exclusively contracting withQ. El 1:1 C3licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCELND.
and Professions Code: I'he Contractor's License Law docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts torsuch projects with a contrdelmos)licensed pursuant to SEWER-SANITARY-STORM EA.200ft110.00
Be Contractor's License Low. TRACT NO. PARCEL NO.
O Iamcxcmptundcr Scc. T&P.C.let this WATER HEATER W/VENT 6.00 1
reason
Owner_ Date //_� p
�� WATER SYSTEM 5.00
7 ra + ACC.DATE ACC.FILENO,
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
I hereby affirm that I have a certificate of,cnwnl losclf-ins,ur, ZONING ENG.SITE No-
or ,a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sea 3800,Late.C.)-
Policy No. Company
O O Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is filed with tire city inspection division. MISC.- REFER TO ORD.
Q Applic:u.t V ❑ N❑ Y ❑ N❑
~ rnPERMIT ISSUANCE 10.00
LU - CCRTI FICATI° I X TION FROM WORKIiRS' FLOOD ZONE A.L.u.c.
W 7 COMPENSATION INSURANCE the PLG.CONTR. LIC.NO, PLG. Y❑ N❑ Y❑ N❑
� Z This section need ,hot be completed if the permit is for one TOTAL
hundred dollars IS 100)or ICss.)
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
UL H shit is issued, I shall blot employ any person in any reamer so its to
0.w become subject to lire Workers'Compensation Laws of California.
LU Data Applicant ALTER OR ADD TO MECH. 5.00 BUILDING /
} 0 NOTICE TO APPLICANT: If,after making this Certificate of Fix-
F Z emption,you Should become subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK LL
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be demned revoked. AIR HANDLING UNIT(TO 10XMC.F.M.) 4.00
CONSTRUCTION LLNU1NC AGENCY AIR HANDLING UNIT(OVER 10)000CF.M.) 6.00 SEISMIC FEE �)
m th .
I hereby affirm there is a construction lending agencv for EXHAUST HOOD(WITH DUCT) 5.00 -'
the performance of the work for which this permit is issued fSec. MICROFILM
3097.Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)Lender's Address ELECTRIC
I certify that l have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
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 BTU)SEE FEE SCH. MECHANICAL
above mmntioned property for inspection purposes.
(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
granlingof this permit. MECH.CONT, LIC.NO. MECH.
C{1 -�Y TOTAL TOTAL
.1 of Apthhn int -ontraclor Date
INSPECTOR COPY -