8486 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDINGts'DnEssAPPLICATION 2 ti/'7 dl/ £ Q APPLICATION & PERMIT ((�� /� ((��
BUILDING-ELECTRICAL-PLUMBING -MECHANICAL !'S4 to
A 11i 8"1 VV
O.REAS PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
- PHONE .
I NAME AG OUTLETS-SWITCHES-RECEP10.00/1.00
nuc.NO. LIGHTING FIXTURES 10.00/1.00
co T Actors
AOOHEss APPLIANCES-RESIDENTIAL 4.00
rROrvE PANELS 10.00 DATE OF APPLICATION
oR IT T PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.No.
ENGINEER
uc.NO. SIGNS TRANS. 3.00
ARCH,OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP rrEMP,METER OR POLE INS. 20.00
ADDRESS s MOTORS SEE FEE SCH.
AOREss
SERVICE CHANGE 20.00 ,{/.Ij(- f✓J^ 1
o o LICENSEDCON'1'RACTORS DECLARATION TEMP.POLE 30.00
M, v w1 hereby'Gunn that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w a w (commencing will,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 I
oi w License Class Lia NumberEl
F y F J Datc Contractor ❑ /
¢ m s -a BUILDING PERMIT
IS a ¢ OWNER-BUILDER DECLARATION
D a O MISC.- REFER TO ORD INFORMATION
Is A w I hereby affirm that I am exempt from the Contractor's License
u4to Law For the following reason.(Sec.7031.5.Businessand ProfessionsPERMIT ISSUANCE 10.00 VALUATION S/FT.
Code:Any city or county which requires a permit to construct,alter,
p p y r or to its issuance,also ELEC.CONTR. UC.NO.
SC
¢ ¢ 0 improve,demolish,or repair an structure,prior ELEC.
D u requires the applicant for such permit to file"a signed statement that TOTAL ERMIT TO
A w m he is licensed pursuant to the provisions of the Contractors License
Uzi
Law(Chapter9(wmmencing with Section 7000)cf Division 3 ofthe
¢
Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
EiD
AJ
the basis for the alleged exemption.Any violation out Section 703 t.5 STORIES TYPE CONSTR.
a ; by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ 1,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 DRAINS-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
.cuts are not hrough
ownffered for sale.
It,
ed that however,the
improve- GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
mems are not intended or offered for sale.IL however,the bol Wing
or improvement is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
Provef will have the burden of proving that he did not build or im RES IND CON PB Omer
Prove for purpose of the.l. INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,he exclusively c 7044,[Ing with ❑ ❑ ❑ ❑ ❑
anti Pno contractors m construct the pricer La 7044,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
to n owner of Cade:The who
's License s th does not apply
to an cts for
of property who builds tr improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractorl9 licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec. .B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a'certificate of consent to self-insure. ZONING
or a certificate of Workers'Compensation Insurance,or a cenified ENG.SITE NO.
copy Ihcreof(Sec.3800,Lab.C.L
Policy No. Company
O ❑ Certified copy is hereby in...Med. FIRE SPRINK ENERGY TQ4
'Z Z ❑ Certll'icd copy is Filed with Dm city inspection division. MISC. REFER TO ORD.
F O Applicant Y ❑ N❑ Y ❑ N❑
f y CERTIFICATE OF EXEMPTION 17ROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE AL.U.c.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLO.
Z t' 1'his section need not he completed if (lie permit is for one TOTAL Y❑ N❑ Y 1:1 No
hundred dollars IS 100)or less.)
U O I certify that to the performance of the work for which this per- GTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL f- mit is issued,I shall not employ any person in any manner so as to
O become subject to the Workers'Compensation Laws of California.
aT UatclL.-�tC.\pplicem ' ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE'f0 APPLICANT: I t r ma'ing us C R Ica[c o :x-
F 2 enlption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
Provisions of the Labor Code, you most forthwith comply with FEE
U such provisions or this permit shall be demned revoked. AIR HANDLING UNIT(TO 10)000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER Iff0 C. M.) 6.00 SEISMIC FEE
I hereby affirm that there is a ansiruclum lending agency for EXHAUST HOOD(WITH DUCT)
thu, er097,CPorramare of the work for which this Permit is issued(Sec. HEATING UNIT(TO 100,000 B.T. .) 8.00 MICROFILM
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify dim I have read this application and state that the above VENTILATION FAN (SINGLE) 4.
information is correct. I agree to comply with all city and county � v PLUMBING
ordinances and state laws relating to building con..bction, and BOILER-COMP(3 H.P.or 100,000 B} .U. 6.00
hereby authorize representatives of this city toenter upon the BOILER-COMP IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgnm nls, co.Is and expenses which CONST.TAX
may in any way accrue against said City io consequence of the PERMIT ISSUANCE 1
gr:mting of this permit. MECH.CONT. LIQ NO. M CH.
TOTAL TOTAL
Ignorant, 'cant n ct a fe,
INSPECTOR COPY