8321 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FI CATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 8 i
OwNER'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
CONTRACTORS�
NA / OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO. LIGHTING FIXTURES 10.00/1.00
WNTHACTOR'S - APPLIANCES-RESIDENTIAL 4.00
ADDRESS
�. PHONE � PANELS 10.00 DATE OF APPLICATION
ORRCHrtFLT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER
Linc.No, SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS. 20.00
ADDRESS tis MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 c��
T
o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
'
asu I hereby amnn Otat I an,licensed under provisions TChapter 9 ISSUANCE DATE
wu (commencing with Section 7000)of Division 3 of the Business and
a 13LDC. ELECT. PLG. MECH.
F w i License Gla Coda and my license i. in full fore t unJ effect ❑ ❑ 12 ❑
z License Class L Lin.Number
' O w F � Data Contractor
a y E BUILDING PERMIT
¢ ¢ ¢ OWNER-BUILDER UGCLA RA'I'ION
0 0 0 INFORMATION
wg u y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u0a Law for the followingreason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 1000 VALUATION $/FT.
� -V, I Code:Any city cocounly which requires a permit to construct alter,
ot � � ELEC.CONTR. LIC.NO.
¢ Sr improve,demolish,Or any structure,prior to its issuance,also ELEC.
K,, Oo LL requires the applicant for Such permit to file a signed statement that TOTAL PERMIT TO
A w Al w he is licensed pursuant to the provisions of the Contractor's License
z¢ Law(Chapter 9(commencing with Section 7000)of0ivision 3 ofthe
i D Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE L- /r
¢ r p the basis for the ullcgcd exemption.Any violation,ofSccti..7031.5 STORIES TYPE CONSTR.
au n 3 -- by any appllcanl for a permit subjects the a,licant to a civil penalty
of not ilmrc than five hundred Jill...($5010).) ALTER-DRAIN&VENT-WATER (EA.) 5.00
0 1,as os4ner of the property,or my employees with wages as BACK F LOW PROTECT. DEV ICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for,sale (Sea 7044. Business and PrOfe..far, DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds OL improves thereon,and who does such work FIXTURES-PER TRAP 5.00 sea FT.FLOOR AREA TOTAL ACREAGE
• himself re through his oxo employees.Provided that such improve-building
hients mself are throuhh isot oroffered emploees,safe provided that such
rbudding GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
or improvement is Sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or int- BUILDING USE
Pollee for purpose of sale.). 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. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law docs not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts l'or such projects with a contractor(s)licensed pursuant m SEWER-SANITARYV-STORM EA.200ft/10.00
the Contractor's License Low. ,L( TRACT NO. PARCEL NO.
0 1'dm exempt under Sec.-,15&P C for this WATER HEATER W/VENT 6.00
1'ealu,n
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COM PENSA1ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure. ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof Sec.38 Lab C..
Policy Nj� ty
❑ Cerb ledcopy is hereby furnished.
FIRE SPRINK ENERGY T 24
Z Z 0 Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
0 Applicant Y ❑ NO , Y ❑ NO
CC S2 CERTIFICATE OF EXEMPTION('ROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLO.CONTE. LIC.NO. PLG.
CL 0 (This section need not he completed it the permit is for,one TOTAL 1$0,0C Y❑ N❑ Y ❑ N❑
D Z hundred dollars IS 100)or less.
U O I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued, I shall not employ any person in any manner so as to
become subject to the Workers'Conlpatmtion Lows of Califomi..
a Datc Applicant BUILDING
>_ tin NOTICE TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
F Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code. you must forthwith comply with FEE
U such provisions Or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10OWOEM.) 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
3097,Civ.C.. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
AddreHEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's ss
I certify that I have rreadthts.pplic.linnond st.te that tam above VENTILATION FAN (SINGLE) r' 4.00
- information is correct I agree to comply with all city and county PLUMBING W
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00 o
hereby authorize representatives of this city to cont. upon the BOILER-COMP(Over100,000BTU1SEEFEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep hornless the City of MISC.- REFER TO ORD.
Cupertino against Babilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
grt of hi pC nil: MECH.CONT. LIC.NO. MECH.
/ TOTAL TOTAL
Si are of pplicanTiCont.etor ' a
U INSPECTOR COPY