C8136 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES - USE BALL POINT PEN ONLY
BU LOING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT V 813 A
ADDRESS b
BUILDING-ELECTRICAL-PLUMBING-MECHANIC
OW ER'S - PLAN CHECK VALIDATION
NAME
HOTV. ELECTRIC PERMIT FEE
V('h t(Ii A - PHONE ') I
CONTRACTORS NAME UT-LENS-SZ
10.00/1.00
..� pr LIC.NO. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
OR's APPLIANCES-RESIDENTIAL 4.00
CONTRA
PHONE PANELS 10.00 DATE OF APP LICATION
AARRCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE V.C.NO.
O
ENGINEER
LIC.no. SIGNS TRANS. 3.00
AARCH.OR DDRESS ENG, SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
1 AvvucANTS
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
w o O LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
U v I hereby affirm that I am licensed ander provisions Of Chapter 9 ISSUANCE DATE
y,a oai (conunencing with Section 7000)of Divisimn 3 of the Business and, BLDG. ELECT. PLG. MECH.
F N z Professions Code,unit my license is in full force and effect. ❑
z o m - License Class Lia Nmob.r ,...❑.,�,
o z ea
Dmi Contmctar
a m f -a BUILDING PERMIT
w 0 U OWNI;R-BUILDER DECLARA'PION INFORMATION'
0 6 A. I- I hereby affirm that I am exempt from the Contractor's License MISC.'- REFER TO ORD
LL o a Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
� - to Code:Any cityor county which requires a permit to construct,alter,
QQ¢ 0improve, or repair any structure.prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. /I
to
- 0 n requires the applicant for such permit to file a signed statement that TOTAL PERM 0
a w m w he is licensed pursuant to the provisions of the Con(r-.¢lor's License y
Fz>
Law(Chapter 9(Commencing with Section 7000)of Division 3 of the /
a Business and Professions Code)or that he isexempt therefrom and OTV. PLUMBING PERMIT FEE i
it r c the basis for the alleged exemption.Any violation of Section 7031.5 W STONES T PE CONSTFT_
n ; m by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred drilla..($500).):
❑ I,as owner of lire property,or my cmPloyces 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(SCC. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Controetor's License Law does not apply to an owner of
property who builds or improves thereon,and who lines such work FIXTURES-PER TRAP 5.00 SD.FT.FLOOR AREA TOTAL ACREAGE
• himself re through his own employers,provided that such improve
hiet Is mself a throuiot gh
or employees,ffered for prove. ided
thathowevs the building GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4(EA.) 200
builder will have the burden of proving that he did not build or im- . BUILDING USE
P
for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RE IND CON PB Other
as.,
s owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
1i n contractors to construct the project(Sea 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
d 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 co tractorls licensed pursuant to SEWER-SAN V-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ 1 am • c opt undo ee. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Own, JWATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
f' WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP, s 5.00
I hereby affirm that I have a certificate of caucnt to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof IS".3800,Lab.C.).
Policy Nn. Company
O O Certified copy is hereby furnished.
FIRE SPRINK ENERGY TN
❑
Z Z ❑ Certified copy u filed with D
Y ❑ NV E]ue city inspection division. MISC.- REFER TO ORD.
0 Applicant
y CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 PLOODZONE A.L.U.C.
W > COMPESSAIION INSURANCE PLG.CONTR. LIC,NO. PLG
Z (Phis section need not be completed if the permit is for one TOTAL Y❑ N El Y❑ N 1:1
hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
IL F mit is issued,I shall not employ any person in any manner so as to
U W become subject to the Workers'Compemation Lows of California.
Dam Applicant BUILDING
>_ b NO'Il CE TO APPLICANT. If, after nuking this Certifmute of Ex- ALTER OR ADD TO MECH. 5.00
etnption,you should become subject to the Workerli Canpcusution APPLIANCE 5.00 PLAN CHECK
Provisions of the Labor Code, you must orthwith comply with FEE
U such provisions or this permit shall be devised revoked. AIR HANDLING UNIT(TO 10OWC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction finding 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 Nam.
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application quid state 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-COUP(3 H.P.or 100,000 B.T.U.) 6.00
above eutimrii representatives ec this city m enter upon the BOI LER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
hereby authorize
property for inspection purposes.
(We) agree to save, indemnify and keep hunnlese the City of MISC.- REFER TO ORD.
Cupertino against liabilities, u •mems, costs and expenses which •PERMIT ISSUANCE 10.00 CONST.TAX
nay In any way accrue a .nirjs said City in consequence of fit, "
granlingn Ihi, •nil. MECH.CONT. LIG NO. MECH.
�
� -fry/ TOTAL TOTAL
1G" g tme.fAppltcant/CoMraclor Dam D
INSPECTOR COPY