8401 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT ��
AOOREss
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
AAZ
OWNERI � PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
• )
Ai o PRONE
NAME CTDR OUTLETS-SWITCHES-RECEP 10.00/1.00
I r LIGHTING FIXTURES 10.00/1.00
roerRAc aR' PPLIANCES-RESIDENTIAL 4.00
_AOOREss S/' --y.
�i y, PH�NE /� �/ N PANELS 10.00 DATE OF APPLICATION
RC TEcr PA NELS I OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
No. SIGNS TRANS. 3.00
ADDRESS ENG' SPECIAL CIRCUIT 5.06 PERMIT VALIDATION
zlP�e/^ EMP.METER OR POLE INS. 20.00
APPLICANT SMOTORS SEE FEE SCH.
ADDRESS
AooR
SERVICE CHANGE 20.00
woo LICENSED CON'I'RAC'IORS DECLARATION I TEMP.POLE 30.00
u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
¢ z w (Commencing with Section 7000)of Division 3 of the Business and - BLDG. ELECT. I PLG. MECH.
wi Professions Code,and my license is in full force and effect. ❑
Z,o m- License Clas��G,__ _Lic.Number
o v, r Dale z-�-fry--E, Contractor ")
a y F �� -/ G L BUILDING PERMIT
¢ ¢ w ¢ OWNEK-BUILDER DECLA KATION INFORMATION
REFER TO ORD u y I hereby affirm that I am exempt from the Contractor's License MISC. VALUATION $/FT.
FLL0 J Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code Any city or county which requires a permit to Comiruct,alter,
¢ ¢ Q 2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
- O R requires file aPPliCaml for such permit to file a signed Statement that TOTAL PER MIT TO
n w he is licensed pursuant to the provisions'of the Contractor's License
Fyi
Law(Clmpier9(Coanimcing wit h Sect ion 7000)of Division Sof the
¢ Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
s4D
Ie I- the ny aper the alleged a ermit subjects
is the
applicant
oto action malty STORIES TYPE CONSTR.
a ';;� by any applicant fora permit subjects tlaant toacivil penally ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred Dollars(S5000.):
❑ I,as owner of the property,or my employees with wagesas 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 talc(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,GOND. 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 iQ it,
' SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve_
Rents are not intended or offered for sale If.however,the building GAS-EA.SVSTEM-1 INC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of pmving that he did not build or int- RES IND CON PB Omer
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 C3 ❑ ❑ ❑ ❑
C, I,as conowner of the property,am exclusively contracting with
licersxd tractors to construct the project(Svc.7044,Business - LAWN SPRINKLERS-I INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:1'he 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 contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ 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.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate ofconsent to self-insure, ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sec 3800,Lab.C.).
Policy No. rlc.� Company :P.,115 'rr)4
Q ❑ C, iedpy is Iter.by fumished. FIRE SPRINK ENERGY T-24
Z Z ❑ Ccrtificd-copy iso- d wit h. the city in,grection division.
O Applicant - r MISC.- REFER TO ORD. Y ❑ N❑ v ❑ No
~ w •`�. PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU - CCK IFICATF E IAiIO"fINS FROM WORKERS'
W COAIPENSA'I'ION INSURANCE PLG.CONTR. LIC.NO. PLG.
EL O (This section need not be completed if the Permit is for one TOTAL (Y Y❑ No Y ❑ N❑
::) Z hundred dollis(S100)or less)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
U becumo subject to the Workers'Conhpensation Laws of California.
O_ Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE TO APPLICANT': If,alter making this Certificate of Ex-
F Z eruption,you should become subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK
prissiness of the Labor Code, you must forthwith comply with FEE
U such provisions or this pernhit shall he deemed revoked. AIR HANDLING UNIT(TO 1Q000QF.w 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lording agency for EXHAUST HOOD(WITH DUCT) 5.00
the pertorcance of the work for which this permit is issued(Ser. MICROFILM
3097. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender Address
HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I Certify that I have read this application and 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-COMP(3 H.P.Or l00,000B.T.U.) 6.00 1,2 ,
hereby authorize representatives of this city to enter upon the
above mentioned property for inspeclion purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
Braiding ofthis permit. MECH.CONT. LIC.NO. MECH.
OTAL TOTAL
Signature of Applicant/Contractor Date
INSPECTOR COPY
I