8768 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 88
ADDRESS7717q itF)iMr ( b
IL G-ELECTRICAL-PLUMBING-MECHANICAL 76
OWNER'5 .� PLAN CHECK VALIDATION
NAME Q Y. ELECTRIC PERMIT FEE
NAME -
• , RD ,
A R UTLETS-SWITCHES-RECEP 10.00/1.00
IGHTING FIXTURES 10.00/1.00
CONT CTOR' LIANCES-RESIDENTIAL 4.00
ADDRESS
_ E A ELS 10.00 DATE OF APPLICATION
ARCIT PA ELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
uc,NO. SIGNS TRANS. 3.00
ADDRESS cies. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZhP EMP.METER OR POLE INS. 20.00
ASMOTORS SEE FEE SCH: ((.),O-'"`^,'�•0..•�'_
ADDREDDRESSS
SERVICE CHANGE 20.00 L /Q
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 O/✓/ D
M U 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and
a vAi BLDG. ELECT. PLG. MECH.
F m z License Cl.Code,and my license is in full for fe t ❑ ❑ ❑
z o w- License Class Lin Number
o � H �
Date Contractor 157.
m F
EE Ica DVM' BU ER DECLARnno�' BUILDING PERMIT
o a INFORMATION
R
; n H I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
F u o ef Law for the following risen.(Sen 7031.5,[hoinessand I'rofessiuns PERMIT ISSUANCE 10.00 VALUATION $/FT.
Code:Any city or county which requires a permit to construct,alter,
ou¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
in
- O LL Inquires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
K
$ hC is licensed pursuant to the provisions of the Contractor's License
r
Law(Chapter 9(comnrencing with Section 7000)of Division 3 oftle
iao Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE L a (Y
M E_o the basis for the alleged exemption.Any violation of$ect ion 7031.5 STORIES TYPE CONSTR.
a3=' by any applicant for a permit subjects to applicant to a civil penalty
of not more than five hlmdred dollars($500).1. ALTER-DRAIN & VENT-WATER (EA.) 5.00
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 Dec.GROUP RES.UNITS
their sole compensation,will do the work,and the slnelufe is not
intended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AR EA,CON D. 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 SD.FT,FLOOR AREA TOTALACREAGE
• himself or through his own employees.provided that such improve-
meats are not intended or offered for sale.IL however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will)live the burden of proving that he did not build or inh- BUILDING USE
prove for purpose ofsale.l' - INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
❑ 1,as owner of the property',am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7(144,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:'tile 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 u contractors)licensed pursuant to
the Contractor's License Law. S EWE R-SANITAR V-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Ses. ,B.&P.C.for this WATER HEATER W/VENT 6.00
realm
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to scl Ginsure. ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurunm,or a ,rtifi.1
copy in rad c J x
Policy
O ❑ C 1 dL lis y r is ed. FIRE SPRINK ENERGY T 24
z Z ❑ Cert' d copy 1 d with the city inspecti n li si MISC.- REFER TO ORD.
O Applicant Y ❑ N❑ Y ❑ N❑
CC y VV 1`1
CE IEI CATE OP HXF:NIPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LL COMPENSATION INSURANCE. PLG.CONTE, LIC.NO. PLG.
( CL H his ecctain eed not be completed it the pennit is for one TOTAL Y E] N❑ Y E] N❑
Z
hundred dollars(S 100)or less)
7U O 1 certify that in the Performance of the work for which this per- DTV. MECHANICAL PERMIT FEE .FEE SUMMARY
U_ F mit is issued,I shall not employ any person in any manner so as to
Q L) become subject to the Workers'Compensation Laws of C lifornia. `
a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE TO APPLICANT: If,after making Itis Certificate F,,..7
♦- ? coalition,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply will FEE
U such pR visioae or this pennit shall be deemed revoked. AIR HANDLING UNIT(TO 10)000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 1Q00
,0C.F.M.) 6.00 SEISMIC FEE
s I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
}S' the Pcrlimnance of the work for which this permit is issued(Sen MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name H EATI NG UNIT(OVER 100,000 B.T.U.)9.50
Lender's NAddresames ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
soolonnalion is correct. I agree to conhply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMPO 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 IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agrip to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs a��phhd expenses which CONST.TAX
e
may in any way accruagainst Said City in SoOsequence of the PERMIT ISSUANCE 10.00
gr ming of this perm). x F 1 1L 1 -7H.CONT. LIC.NO. MECN.
I'�/ TOTA` TOTAL
r C p a nt ct to
INSPECTOR COPY