C8694 APPLICANT TO FILL IN INFORMATION WITHIN,RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
D
ADRESSILDIN APPLICATION & PERMIT 8694
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
0 RES PLAN CHECK VALIDATION
NAM
OTY. ELECTRIC PERMIT FEE
vRONE
NAME ,a OUTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
-G T AG*oR' /1
ADDRESS PPLIANCES-RESIDENTIAL 4.00
1-� �
V� PRONE PANELS 10.00 DATE OF APPLICATION
OR
�REETTECT-
PANELS OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC,NO. SIGNS TRANS. 3.00
ADDRESS
OR ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS. 20.00
APPLICANT MOTORS
ASEE FEE SCH.
A
_ SERVICE CHANGE 20.00
w o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
A z w 1 hereby afflrn that I mm licensed under provisions of Chapter 9 'ISSUANCE DATE -
a vAi (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r•N z Professions Code,a d eny license is in full foyer an (I'ect
.
oi m o Isale se Class_ C.G Gm I., ❑ ❑
F m J Dalc Contmaror
BUILDING PERMIT
¢ ¢w a OWNER-BUILDER DECLA RATION,rc..v i <-
o a u INFORMATION
K
3 LL I- I hereby affirm that I am exempt Rom the Contractor's Licenze MISC.- REFER TO ORD
uLL Law for the following reason. 7031.5,Business and Professions tn_n0 VALUATION $/FT.
H - PERMIT ISSUANCE W ��
Cole:Any city ur county which requires a permit to construct,al@m
Qaa improve,demolish,or repair any structure.prior to its issuance,also ELEGCONTR. LIC.NO. ELEC.
C¢ requires(lie applicant for such permit to file a signal statement that TOTAL `Z PERMIT
a w m he is licensed pursuant to the provisions of the Contractor's License
r z i
Law(Chapter 9(commencing with Section 7000)of Division 3 cfthe C
f ¢ o Business and Professions Code)or that he is exempt therefrom and 1
¢r the basis for the alleged exemption.Any violation of Section 7031.5 OTV. PLUMBING PERMIT FEE
RIES T E- 0 ST .
u 3 by any applicant for u permit subjects the applicant to civil penally -
ofnot mom than five hundred dollars(S5OOL): ALTER-DRAIN& VENT-WATER (EA.) 5.00
Cl 1,as owner of the properly,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 DRAINS-FLOOR,ROOF,AREA,COND: 5.00
Code:The Contractor's License Law does oat apply to an owner of
properly who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5,06 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such inhprovc
-
meatsarenotintended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner- /
builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 3UGEDING USE
REB IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ d as owner of the property,he exclusively. 0ructims with ❑ ❑ ❑ ❑
licensed Professions
tore Code: construct the priced(Sec.7044,of apply LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS vgRCEL N0.
and n owner of proa The Contractor's License Law does not apply
to tr owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
centrads for such projects with v contruaorts)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT N0. PARCEL N0.
O l am exempt under Sec...B.&P.C.for this WATER HEATER W/VENT 6.00
reason
` Owner Dare WATER SYSTEM 5.00 Ace.ogre ACC.FILE No.
WORK ERS'COMPI:NSA'I ION DECLARATION WATER TREATING EQUIP. 5.0 _
a I hereby affirm that I have a certificate of consent to self:insure, i
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No. Conhp;ury
0 ❑ Certified copy is hereby furnished.
Z Z 11 Certified copy is filed with the city"ins Pection division. FIRE SPRINK ENERGY T"24
O Applicant MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
~.yPERMIT ISSUANCE 1 0 FLOOD ZONE A.L.u.c.
CER"1'IFICATE Oh'1 XEMI'TION PROM WORKERS' �D
LU COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG,
CL 0 1'1'his sectionneed not be completed if the Permit is for one TOTAL Y❑ NE] Y [:] NEIZ) Z hundred dollars IS 100)
or less.)
U O 1 certify that in the performance of(lie work tor which this per. QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued.I shall not employ any person in any manner so as to
1 O 0hecome subjeIct to tl WorkeryCompensa'on Law:of Calif niv.
Dee �t ALTER OR ADD TO MECH. 5.00 BUILDING S"L1
>- W NO7 TT I'1' I A : If, n ma ing hls Ccrllfi tc o .x-
F- Z mnprunh,you should hecome subject nn the Workeri Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply will, FEE
U such provisions mr this permit shall be deemed rm'oked. AIR HANDLING UNIT(TO 10,000C.F.M,) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm thin there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued ISce. MICROFILM
3097,Civ.C.). - HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
-
Lender's Address ELECTRIC
I certify that I have read this application and Stam that the above VENTILATION FAN (SINGLE) 4,00
-® informre
ation is corct. 1 agree to comply with all"try
and c..my PLUMBING
ordinances and State laws rclaring to building construction, and BOILER-COMPO H.P.or 100,000 B.T.U.) 6.00
Hereby aullsOme representatives of this city to enter upon the BOILER-COMP (Over 100.000 BTUI BEE FEE SCH. MECHANICAL
above-mentioned property]or inspection purpo+es.
(We) agree m save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgnhents, costs and expenses which CONST.TAX
[antingortl
ay in any w acme anuml uid City in Consequence of the PERMIT ISSUANCE 10.00
s R MECH.CONT. LIG NO. MECH.
TOTAL TOTAL no SV
gna o pp
/Contractor ate
INSPECTOR COPY