8531 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
BU I LDING PROJECTlDENTIFICATION APPLICATION & PERMIT
BUILDING 8531
ADDRESS
DING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
"AME CITY. ELECTRIC PERMIT FEE
' ONE
SF
NACONoRA oR
MEUTLETS-SWITCHES-RECEP 10.00/1.00
uc.No. LIGHTING FIXTURES 10.00/1.00
COTRACADDRESS R PPLIANCES-RESIDENTIAL 4.00
I PHONE PANELS 10.00 DATE OF APPLICATION
.q ORRCHI CT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE D.C.N0.
Y ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENG.
SPECIALCIRCUIT 5.00 P DATION
ZIP TEMP.METER OR POLE INS. 20.00
Ara
ADDRESS MOTORS SEE FEE SCH. JUN 5
DRESS E55
J.
SERVICE CHANGE 20.00
w o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 City Of Cupertino
F z w I hereby affirm that I am licensed under penskimo of Chapter it ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and
may BLDG. ELECT. PLG. MECH.
h z Professions Co an I y ficense is in full fore
e a '
Lro7a•J
z O y - License Clunx - Lie.Number El
mw Uulc Contrunor
a x f BUILDING PERMIT
¢ ¢a ER-BUILDER DIiCL I
apo INFORMATION
wLL y I herehy affirm that 1 um exempt fiom eCuntucfori License MISC.- REFER TO ORD
Hu04 Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
Code:Any city or county which requiresa permit toconslruc.alter,
J Q Q ¢ Improve,demolish.or repair any structure,prior to Its issuance,also ELEC.CONTR. LIC.NO. ELEC.
4 W m LL reHaires the applicant for Such permit to file a signed statement that TOTAL PERMIT TO
he is licensed pursuant to the provisions of the Contrmtor's License
r zi
Law(Chapter')(commencing with Section 7000)of Division 3 of the
i a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ r-o the basis for the alleged exemption.Any violation of Section 7031.5 STORES-S•' YPE CONSTR.
W
. by any applicant for a permit subjects the applicant to a Civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five Inum red dollars(5500).):
❑ l;as owner of the property,or myemployes with wages as BACK F LOW PROTECT.DEV ICE 4.00 OCG GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,GOND. 5.00
Code:The Contractors License Law does not apply to an owner of
property who builds of improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT,FLOOR AREA TOTALACREAGE
nhint'elf it Through h'' con unployee"Imovidul that net,intProse-
entsaenot:mended or offered for sale If,however.the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
. .ur improtemect 's sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) - 2.00
bald r will'Emse the bunlerofproving that he did not build or Int. _ _ BUILDING USE
prove for purposeofsal ). .° INDUSTRIAL WASTE INTER.' •$Q.OQ ^•RES •- IN CON rPe Omer
❑ I,as owner of the imperty,ion exclusively contracling with ❑ -� 0
licensed contractors to construct tie project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Profissions 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 contructons)licensed pursuant to
the Contractor's License Law. •� SEWER-SANITARY-STORM EA.200tt/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,L&P.C.I'Ot this WATER HEATER W/VENT 6.00
reason '111
Owner Date WATER SYSTEM 5.00 ACC.DATE ACG FILE N0.
WORK E RS'COMPENSATION DIECLARATION WATER TREATING EQUIP. 5.00
1 hereby infirm that 1 have acertificute ofconsent IOSelf-insure, ZONING ENG.SITE N0.
or a certificate of Worker:Compensation Insurance,or a certified
c py e�f��f•ff,, ( .b.CJ.
QICllle ice Pby flfl nt FIRE SPR INK ENERGY T-24
Z 2 O Certified copy i fled wi tl th• city inspection division.
O anr1j.A
MISC.- REFER TO ORD. y [] N� v ❑ No
f- PERMIT ISSUANCE 10.00
S2 CPP EXEM1I PTION PR MWORK:RS'- oDZONE A.L.U.C.
W I: PLG.CONTR. LIC.NO. PLGY N v NEI
CL0 (This ot be completed if the permit is for one TOTAL
hundred dollars(SI00)or Itss.)
U O 1 certify that in the performance of the work fur which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any Illanner so as to
U W become subject to the Workers'Compensation Laws of California.
It. Date Applicant BUILDING
} W NOTICE:TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
m
? .mption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
Provisions of tlm Labor Code, you most forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.W 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLING 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 performance of the work for which this permit is issued(Sec. MICROFILM
3077,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Nam. HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I Certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all City and county PLUMBING
nrdirunces 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(Over 1110,000 BTU)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
ay in any way recruit, against said City in conmyuence of the
'mogOf ispermit. MECH.CONT. LIC.NO. MECH.
h )Dq TOTAL TOTAL
,ijurrit.Wypp Ivan ntmcto Do[ re"�
INSPECTOR COPY
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