C8178 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON PERMIT NUMBER
B ,LDING APPLICATION & PERMIT C
ADDLESs
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
f2 A4 e. lir- 8178
OWNERS PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
ONE q574 16/w
TRA_ NAME cions OUTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
LI L .NO.
CONTRACTOWS PPLIANCES-RESIDENTIAL 4.00
/ ADDnEss 061,
''II '
y [T/, [J•/ oNE 7 4 PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
O
ENGINEER
Llc.Na. SIGNS TRANS. 3.00
ARC.,OR ENG. / PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00
ZIP EMP.METER OR POLE INS. 20.00 (
ADDRESS MOTORS SEE FEE SCH. J
ADDRESS
SERVICECHANGE 20.00
w o O LICENSED CON'I'RAC'IORS DECLARATION TEMP.POLE 30.00 /ds
u I hereby affirm that I are licensed under provisions of Chapter 9 ISSUANCE DATE
M,
a (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
Professions C rut my license is in full force and effe ElO
z o w- hiccnCla' Li,,.Norther F
1 13
o m r O IJme sc "' Contractor
a Y s BUILDING PERMIT
p LL OWNER-BUILDER DECLARATION INFORMATION
X o u m I hemb alfirn IIII 1 am exem t front the Contractor's License MISC,- REFER TO ORD
u u y' P VALUATION $/FT.
F _ o sr Law I'.,the following reason.(See 7031.5,Business and Professions PERMIT ISSUANCE !* 10.00
,qA Code:Any city orcounly which requiresapennitto construct alter, /G
rt ¢ 2O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO.� ELEC. '
ra
- DLL requires the applicant for such permit to file a signed statement that ♦ TOTAL PERMITTO
' w he is licensed pursuant to the provisions of the Contractor's License
A
HZLaw(Chapter 9(commencing with Section 7000)of Division 3 ofthe
sr Business and Professions Code)or Ina( he is exempt therefrom and QTY. PLUMBING PERMIT FEE &5 G /H
K F o the basis fur the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.'
P. by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER IEA.) 5.00 "
of not more than five hundred dollars(S500)J:
❑ 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 lire structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 $0.FT.FLOOR AREA TOTALACREAGE
• himself or through his own employees,provided that such improve-
Precis are not intended or offered for sale.If,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 IEA.) 2.00
builder will have lite burden of proving that he did not build or int- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 REST IND CON PB Omer
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ Cl
licensed contractors to construct the project(Sea 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 an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OV ER 5(EA.) 1.00
contracts]Or such projects with it contractors)licensed pursuant to SEWER-SANITAR V-STORM EA.2001tI10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,B&RC,for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSAI'ION DECLARATION WATER TREATING EQUIP. 5.00 ,
1 hcmby mri"o thus I have a certificate of consent to selGinsure,
or a certificate of Workers'Compcnsalion hhsurlusc,Or a i�1Ncd ZONING ENO.SITE NO.
copy(hereof(Sec.3800,Lab C.).
Policy No. Cn au - -
❑ Ccrlii'icd co S lcre1q; nhi, a. FIRE SPRINK ENERGY T 24
Z_ Z ❑ Certified is filed wit hC ily imlle'tih d' cion. MISC.- REFER TO ORD.
O }' Applicant V❑ N❑ V ❑ N❑
CC CER
PERMIT ISSUANCE 10.00 FLOOD ZONE a.L.u.c.
CIiR"TII ICA'I'E OIy1 EviPTION PROM WORKERS'
W > COMPIi�NrrSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL 0 CL Z (This section need not be completed if'the permit is for one TOTAL Y[:] N❑ Y ❑ N❑
hundred dollars IS 100)or less.)
U 0 I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
IL H mit is issued,1 shall not employ any person in any manner so as to
Ow become subject to the Workers'Compensation Laws of California. BUILDING
D. Dale Applicant ALTER OR ADD TO MECH. 5.00 �j w
>_ to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
(•" Z 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 provision,or this permdoll all be deem00
ed revoked. AIR HANDLING UNIT(TO 10pC.F.M.) - 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE
1 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 Fame HEATING UNIT(OVER 100,000 B.T.U.)Lender's Address ELECTRIC
1 certify)hut I 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 authorise representatives of this city to enter upon the BOILER-COMP (Over 1000OOBTU)SEE FEESCH. MECHANICAL
above-mentioned properly for inspection purposes.
(We) ogre to save, in con'tt t hurmlcss the City of MISC.- REFER TO ORD.
Cupertino : ninst ditie, gmenls, cos. d expenses which PERMIT ISSUANCE 10.001CONST.TAX
a way accrue st said City'in c nsequence of the
rani f tri,permit. - v H.CONT. LIC.N0. MECH.
3!n_g TOTAL TOTAL
Sig turcoloTipplivilicoratmel., Date
INSPECTOR COPY-