C8578 APPLICANT TO FILL,IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADOREssnz 8
w BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
DANE 'B PLAN CHECK VALIDATION
NAME - I TV. ELECTRIC PERMIT FEE
T. � �I/� ONE G.r
riAme CTOR S UTLETS-SWITCHES-RECEP 10.00/1.00
LtC.NO. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S PPLIANCES-RESIDENTIAL 4.00
\/ ADDRESS
HO EI PANELS 10.00 DATE OF APPLICATION
oRcwTEC PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.N0.
ENGINEER
uc.No. SIGNS TRANS. 3.00
ADDRiiSS emc. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION.
ZIP TEMP.METER OR POLE INS. 20.00
t Ar
SNs MOTORS SEE FEE SCH.
( ADDRESS
SERVICE CHANGE 20.00
f woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 4
/7z/fs
Fz w I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
Q an (Commencing with Section 7000)of Division 3 of the Business and BLpC. ELECT. PLG. MECH.
t- N i Professions Code,•'}qA my license is in full force and ef(ec t. ❑ ❑ ❑ ❑
zo 0 y o License Class-LS Lic.Number
w F Date h� ;,tor
cmr
m s `1"�5 - - BUILDING PERMIT
6o i O
OWNER-BUILDER De INFORMATION
X 3 LL t- I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
u o j Law for the following reason.(Sec.7031.5,Businessand Professions pERMIT ISSUANCE 10.00 VALUATION SIFT.
� - w Code:Any city or county which requiresa permit to construct,alter,
Qas Q p improve,demolish,or repair any structure,prior 10 Its Issuance,also ELEC.CONTR. LIC.NO. ELE
K m LL requires the applicant for such permit 10 file a signed statement that TOTAC
L PERMIT TO
i' or he is licensed pursuant to the provisions of the Contractor's License
rzQ
Law(Chapter 9(commencing with Section 7000)of Division 3 ofihe j.(�A•�.�-
i 0 QTV. PLUMBING PERMIT
Business and Professions Code)or that he is exempt therefrom and FEE
c-m the basis for tire alleged exemption.Any violation ol'Section 7031.5 STORIES TYPE CONSTR.
f a3 - by any applicant fora permit subjects the applicant toa civil penally ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollar,($500).) _
` ❑ 1,as owner of the property,or my cmployces with wages as ggCK FLOW PROTECT. DEVICE 4.00
their sole co upensalion,will do the work,and ire structure is not OCC.GROUP RES.UNITS.
intended or offered for sale (Sec. 7044, Business and Professions t
DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Coda:The h....builds or License.Law docs an apply to cot owner of
property or through
builds or impRAcs thereon,and whoadoes t such
work FIXTURES-PER TRAP 5.00 ser Pr.FLOOR AREA TOTAL ACREAGE
` • hici Is re through his own umplo Nees.provided that such im building
r not sold oroffered
on yearrdr.oIhowever,the building GAS-EA.SVSTEM-11NC.40UTLETS 8.00
r builder
ill bas is sold within one year of completion,tie owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving flat he did not buil)or im- BUILDING USE
prove for purpose o(sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
❑ 1,as owner of the property,ant exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to Construct the prejeft(Sec 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and 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
i contracts for such projects with a contracmKs)licensed punuent to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.(or this WATER HEATER W/VENT 6.00
Own
reason
' er Date WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO.
fi N'ORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 -
1 hereby affirm that I have a certificate of consent to self-insure. ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a cerli(icd
�.L copy thercofl Sea 3800,'Lab.C.).
/ Policy No. Company
e0 ❑ Cetlifietl Copy Is hereby furmsiB I. FIRE SPRINK ENERGY T 24
'z ❑ Certified a is >-dor' h I city inspeclion division.
O\/ Applicant MISC.- REFER'TO ORD. Y ❑ N Y ❑ N❑
CCN idMfRA� PERMIT ISSUANCE 10.00
O: Cf - A'I'IiO Ii
SEMI" R011 WORKHRg' FLOOD ZONE A.L.U.C.
LU > COMPYNSA'I'[ON INSURANCE PLG.CONTR. LIC.NO. PLG.
rL 0 (Phis section need not be completed if the permit is I'or one TOTAL Y❑ N❑ Y El N❑
hundred dollars(S 100)or less.)
U O - 1 certify that in the perfumtunce of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued.I Shall not employ any person in any mann..so as to
O W become subject to the Workers'Compensation Lawsof California.
0. Date npphc°m ALTER OR ADD TO MECH. 5.00 BUILDING SD
} 0 NOTICE 1'0 APPLICANT: IL alter making this Certificate of rix-
? emption.you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.NL) 4.00
CONST RUCTION 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 1'or which III is
permit is issued(Sec. MICROFILM
3097.Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
NH EATING UN IT(OVER 100,000 B.T.U.)9.50
Lender's Name ELECTRIC
1 certify that I have mad this application and state that the above VENTILATION FAN (SINGLE) 4.00
® imorination 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 100,000 B.T.U.) 6.00
hereby authuriru representatives of this city to enter upon the
abovcanentioned property for inspection purposes. BOILER-COMP (Over l0U,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 PERMIT ISSUANCE 10.00 CONST.TAX
may in ary way accrue agniast �id City' in consequence .1 the
granting of thix permit. MECH.CONT. LIC.NO. MECH.
10 TOTAL TOTAL •yes &
' n' phcun Ir CL Ie
INSPECTOR COPY ,