8385,I
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT '
ADDRESS
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER' PLAN CHECK VALIDATION
NAME -fTY. ELECTRIC PERMIT FEE
c /\Q+-i PHONE 2Q`-`If /� ,.
CONTRACTORS
NAME OUTLETS-SWITCHES-flECEP 10.00/1.00
ti(•vl.L LIC.NO. P2 LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
ADDRESS PPLIANCES-RESIDENTIAL 4.00
1 (/
HONE i J`/O PANELS IO.00 DATE F APPLICATION
U O
ARCHITECT IPLAN CHECK FEE P.C.NO.
OR S `c�re� PANELS (OVER 200 AMP) 20.00
ENGINEER
uc,NO SIGNS TRANS. 3.00
ARCHOR ADDRESS ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP frEMP. METER OR POLE INS. 20.00}- �+
APPLICANT s A::�4S. MOTORS SEE FEE SOH. J
ADDREss
' p a SERVICE CHANGE 20.00 /
0 o LICENSED CON"IRACTORS DECLARATION TEMP.POLE 30.00 �r ��S
< u u I hereby affirm that I wn licensed under pnrvistous of Chapter 9 ISSUANCE DATE fl
H G w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
License Class 8 Lic.Number
H o z Professions Code on'tl my license is in full force and effect ❑ ❑ ❑ ❑
O w -
Z, m r w Dale . Contractor .-I- ,z
BUILDING PERMIT
te � a OWNER-BUILDER DECLARATION
0 o U INFORMATION
X 3 LL N I hereby affirm that I um exempt from file Contractor's License MISC. - REFER TO ORD
u O J Law for the following reason.(Sec.7031.5,Business and Professions VALUATION S/FT.
t - PERMIT ISSUANCE 1Q,p0
Code:Any City or county which run nires a permit to construct,alter,
improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR_ LIC,NO, ELEC.
O u requires tile m
e applicant for such permit to file a signed statement that TOTAL
a w m he is licensed pursuant to the provisions of tileContractor's License PERMIT TO
I- zQ Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe ?C M� 7Z
re z O business and Professions Code)or That he is exempt therefrom and QTY. PLUMBING PERMIT FEE / /
¢ H the basis for the alleged exem shoo.Any applicant
of Sectionero L5 STORIES TYPE CONSTR.
i ; by any applicant fora permit subjects the applicant too civil penalty
of not more than five hundred dollars(5500).1: ALTER-DRAIN& VENT-WATER (EA.) 5.00
❑ I,as owner of the property,or my employees witll 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 Licalse Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PERTRAP 5.60 SO.FT,FLOOR AREA TOTAL ACREAGE
himself ar r through his awn employees,provide)that such improve-
or improvemee notnt is sold or within tune year
If, thebuildingoGAS-EA.SYSTEM-1 1NC.40UTLETS 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 the
or im- BUILDING USE
prove for purpose of the)' INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ d as owner of the property,he 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 properly
Contractor's License Law docs not apply
to an owner of property who builds tr improvos Ihcrco a and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contractsforsuch Lcense tswith acontrucmrts)licensed pursuant to SEWER-SANITARY-STORM EA.2001t/10.00
the Contructar License Lt.. TRACT NO, PARCEL N0.
❑ I am 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.
0RKIS on1p1SN-IrION DECLARATI WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofconsnt to self-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy(hereof(Seo.3800,Lan. _
Policy e Company
❑ Certified copy is Lemny lurmsled. FIRE SPRINK ENERGY T.24
Z ZCernttified copy is filed with the city inspection division.
F0 caMISC.- REFER TO ORD. Y[] N❑ Y 0 N�
CC T CERTIFR.A :OI' >. f:At 1 N rppaM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W > COMPENSATION INSUNINCI: PLG.CONTR. LIC.NO. PLG.
Z CL (This section need not be completed if the permit is for one TOTAL Y Nb Y N�
hundred dollars IS 100)or less I
U O 1 certify that in the Performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any person is any Inanncr so a,to
Ow beannc subject to the Workers Compensal ion Lawsof California.
G. Date Appli`ant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE: TO APPLICANT: If,after making this Certificate of fix-
, ♦- ? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must Iorthwith 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 10=C.F.M.) 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(See. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's NameHEATING UNIT(OV ER 100,000 B.T.U.)9.50
tendo i Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct.1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 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,judgments, costa coldexpenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in ell"" uence of the
granting of this permit. MECH.CONT. LIC.NO. MECH.
( _ TOTAL TOTAL
Z Sig r o A tic nt Contr or ate
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INSPECTOR COPY
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