8656 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT I DENT]FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT ^
ADDasss b
BUILDING — ELECTRICAL—PLUMBING—MECHANICAL
R PLAN CHECK VALIDATION
1 NAME QTY. ELECTRIC PERMIT , FEE
ONE
NAMERAc]oRs UTLETS-SWITCHES-RECEP 10.00/1.00
�^ LIC.No. LIGHTING FIXTURES 10.00/1.00
,orvTRACTons PPLIANCES-RESIDENTIAL 4.00
ADOR Ess
All
NONE PANELS 10.00 DATE OF APPLICATION
ORRCN CT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER
uc.No. SIGNS TRANS. 3.00
AACWOR ENG. SPECIALCIRCUIT 5,00 PERMIT VALI DATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
^. SERVICE CHANGE 20.00 //
w ¢ TEMP.POLE 30.00 y /S S�
Foo LICF,NSED CONTRACTORS DECLARATION.
rt u U I hereby affirm that I am licensed under prm'kimui of Chapter 9 ISSUANCE DATE
w c n (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F y z Professions Code,and my license is in full force and effect.
z o A.— License Class / Lic.Number
r oy Date Contractor
¢ y E N/L„/yq BUILDING PERMIT
¢ OWNIiR-BUILDF:k DIiCLAkA'fl0
¢o v INFORMATION
g LL F I hereby affirm that 1 am exempt from the Contractor's License MISC`— REFER TO ORD
in VALUATION7=
Fuo J Law for the Following reason.(See 7031.5, r¢inessand Professions PERMIT ISSUANCE 10.00
Code:Any city or county wh ich requires o peermit to construct,vlteq
M ¢Q Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTRA LIC.NO. ELEC.
to S, requires the applicant for such permit to file a signed statement that r TOTAL PERMIT TO
E
u. hsu
e is licensed Pennant to the provisions of tire ac
e Contrtor's License
Fes. Law(Chapwr9(conimencing with Section 7000)of Division 3 ofthe
a 'Business and PoWessions Code)cur that he isexempl therefrom and DTV. PLUMBING PERMIT FEE
Eio
¢ F$ the basis for the alleged exemption.Any violation f Section o 7031.5 STORIES TYPE CONSTR.
a ; by any applicant fee a permit wbjectx the applicant macivil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars 155001.1:
O I,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 sale (Sec 7044, Business and Professions OR A I NS-FLOOR,ROOF,AR EA,CON O. 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 AJ FIXTURES-PER TRAP _:L00 (J'e. SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own mnployees,provided that such improve- 40UTLETS 6.00
meats a in not intended mof7ered for sale.If,huwevcq the building GAS-EA.SYSTEM-11 NC.
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 h - . . .
e did not build or im- BUILDING USE
prove for purpose olsaleJ. INDUSTRIAL WASTE INTER. 3000 RES IND CON PB Omer
O 1,as owner of the property,am exclusively contracting with . ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec 7044,Business LAWN S@3 INKLERS-I INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
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 contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
Cl I ael exempt under Sec ,13.&P.C.fm this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
I ACC.DATE ACG FILE NO.
WORK ERS'COMPIiNSA'IION DECLARATION I WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consem to self-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
Copy Ihereof(Sec.3800.Lah,C.). i
Policy No. Company
Q ❑ Certified copy is hereby furnished. w FIRESPRINK ENERGY T 24
z Z ❑ Certified copy is filed with the city inspection division.
10/1 Applicant MISC.- REFER TO ORD. v❑ N❑ I v ❑ N❑
� T CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 1000 _ FLOOD ZONE A.L.U.C.
11J COhIPE-NSATION INSURANCE PLG.CONTE. LIC.NO. PLC.
EL 0 This section need not be completed if the permit is hr one TOTAL C.AJ Y ElN❑ v E] NEI
::) Z hundred dollar,IS 100)or less)
L) O 1 certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I shall not employ any person in any nmmmr sen as to
become subject to the Workers'Compensation Laws of California.
ED Date_ AIII I1'ppl T: _!' ALTER'OR ADD TO MECH. 5.00 BUILDING
_ W NOTICE 'IO AI I'.ICANT: If, ItMITIg 1 .ctl'Icut i
F" ? 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
C..) 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=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the pedormmee of the work for which this permit is issued(Sec. MICROFILM
3097,CN.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT 100,000B.T.U.)9.50
Lender's Address ELECTRIC
Icertify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• information is correct. 1 agree to comply with all city and county PLUMBING
ordinunces and state laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00
hereby author lm representatives of this city to enter upon the
above-mentioned property for inspection purposes. gQILER-COMP(Over t00,000BTU)SEE FEE SCH. MECHANICAL
(We) agree to Save, rudenmify and keep harmless the City of MISC. REFER TO ORD.
\ Cupertino against liabilities,judginents, costs and expenses which
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00 CONST.TAX
rentingofihispennit. MECH.CONT. LIC.NO. MECH.
1
TOTAL
TOTAL
Sig LIR of App c nl/ on ractor ate
INSPECTOR COPY