8382 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
SU I LDING PROJECT IDENTIFICATION PERMIT NUMBER ^
BUILDING APPLICATION & PERMIT
ADDRESS
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 8382
�� �ER�/ OTY. ELECTRIC PERMIT FEE �'"'ELgN CHECK VALIDATION
(- ) PHONE
CONTRACTORS
NAME UTLETS-SWITCHES-RECEP 10.00/1.00
uc.No. LIGHTING FIXTURES 10.00/1.00
r. NTRA44S -
ADDRESS PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
OR
RcwrecT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ervG SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS- 20.00
APPLICANT
ADDRESS \ MOTORS SEE FEE SCH.
° ¢
0j/J(
SERVICE CHANGE 20.00
i
"
Foo LICENSED CONT RACTORB(UF,CLARKI'ION TEMP.POLE 30.00
a U u I herchy atfino Ilia, 1 am li cmacd under provisions of Chapter 9 ISSUANCE DATE
w rt N•� Icommeneag with Section 7000)of Division 3 of the Business and BLO . ELECT. PLG. MECH.
F 7 z 1tt Professions Ccala� d my license is in full mncg�ml of
o i H w License Class 1_-' Lic.Number_: ❑ ❑ ❑
Data _ Contractor
Q y E J
¢ ¢ a WNER-BUILDER DECLARATION BUILDING PERMIT
¢o a v - INFORMATION
A.
H I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
FNEa Law for the fidlowingreasnn.(Sec.703L5,Business and ProfessionspERMIT ISSUANCE 10.00 VALUATION $/FT.
Code:Any city or county which requires a permit to Construct,alter,
Qa a improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO ELEC. /
wO¢ requires the applicant for such permit to file a signed statement that TOTAL J/ PERMIT TO
m he is licensed pursuant to the provisions of the Contractor's License
F i'a Law(Chapter 9(commencing with Section 7000)of Division 3 of the
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ H e the basis nix the alleged exemption.Any violation t toec[ion malty ST TYPE CONSTR.
a3E' by any more
fore permit subjects ilia applicant toacivil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ 1,as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their wle compensation,will do the work.and the,tractor,is not
intended or offered for sale (Sec. 7044, Business and ProfessionsDRAINS-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-
ar
.an(s e not intended or ol'1'cred for sale,If,however,the build;,,, GAS-EA.SYSTEM-1 INC.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 of proving that he did not build or ion- - . - . .
- BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER3000 E IND CON PB Omer
11I,as owner of the property,am exclusively contracting with . .
❑ ❑ ❑ ❑
licensed c.manmors to construct the project(Sea 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 1 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an ownei of properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contructous)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. .BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Duro WATER SYSTEM 5.00 ACC.DATE ACG FILE NO.
WORK ERS'COMPENSAT10N DECLARATION WATER TREATING EQUIP. 5.00
I hereby infirm that I have a certificate of consent to self insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lah.C.).
Policy No. Company �rf�E�ay^- /LI.H1 _
O ❑ Certified copy Is hereby'lmn .
fIRE SPO INK ENERGY T24
Z ZIYCenifuW copy'is fled ilh the oily inspection division. MISC.- REFER TO ORD.
O Applicant/�/� � V E] NNE] V ElNEI
irw CIi(T ICATI _0I F. fiMPr1ON FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE a.L.u.c.
LU > COMPENSATION INSURANCIi PLG.CONTR. LIC.NO. PLG.
0- 1'I'his section need not be completed if tire on
e permit is for e TOTAL v ElN❑ v E] NEI
Z
hundred dollars(S 100)or Less.)
U O 1 certify that in the performance of the work for which this per, OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F out is issued,I shall not employ any person in any manner so as to
O become subject to the Workers Compensation Laws of California.
LU Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} w NOT'C]; APPLICANT: IL
after taking this Certificate of lis-
H Z crinin on,you should become subject to the Worken 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=13C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency lot EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Ci,C.). HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's d
Address me
Lender's AddrHEATI NG UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC I ��
1 certify that l have read this application and sale 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
above-mentioned property for inspection purposes. BOILER-COMP IOve,100,000 BTUI SEE FEE SCH. MECHANICAL
(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 an ay accrue ine agaaid City in consequence of the
gra is permit CH.CONT. LIG NO. MECH.
�J -- TOTAL TOTAL /�
SigmrCure of Applicant/Contractor ate (�'
INSPECTOR COPY