8384 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
.� BUI LDI NG PROJECT I DENT[FICATI ON PERMIT NUMBER
EDILDING APPLICATION & PERMIT
ADDRESS113Z-7 ////^r����
8384 V O f'
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL o o/-jY
OWNE PLAN CHECK VALIDATION
NAME TY. ELECTRIC PERMIT FEE
' M1- PHONE
CONTRACTORS' UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
LIS.ND Z pQ LIGHTING FIXTURES 10.00/1.00
ADDRESSToes DDRESS PPLIANCES-RESIDENTIAL 4.00
CONTRAC
A HONE PANELS 10,00 DATE OF APPLICATION
o CHIT CT I - PLAN CHECK FEE P.C.NO.
Da PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
• IIP EMP. METER OR POLE INS. 2U0
APPLICANTS MOTORS SEE FEE SCH. S'
ADDRESS
SERVICE CHANGE 20.00
o a LICENSED CONTRACTORS DECLARATION TEMP.POLE 30,00
'4/y/6 5
a u U I hereby affirm chat I am licensed under provisions of Chapter 9 ISSUANCE DATE
y a w Icommencing with Section 7000)of Division 3 of the Business and BLDG- ELECT. PLG. MECH.
H w z Professions Code,and my license is in full force and effect. ❑ ❑ ❑ ❑
zO m - License Class Lie.Number
0 z w Dale Contractor
a y f BUILDING PERMIT
¢ ¢ w OWNER-BUILDER DECLARATION
REFER TO OR
INFORMATION
wLL y 1 hereby affirm that I am exempt from the Contractor's License MISC.- VALUATION
LL_0< Law for the following reason(Sec.703L5.Businessund Professions PERMIT ISSUANCE �0 6 S/FT.
Code:Any city orcoumty which requires a permit ro construct,alter,
ac aa¢Q Q improve,demolish,or repair any Mfuctttre,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. ry
Emu requires the applicant for such permit to file a signed statement that TOTAL PERMITTO
A w he is licensed pursuant to the provisions of the Contractor's License
H z r
Law(Chapter 9(commencing with Section 7000)ofDivision 3 of the q
- st Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
¢ o the basis for III,alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
d 3_' by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not nice,Dmn five hundred dollars($500),r
❑ I,as owner of the Property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCA.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
'mended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 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 Sa FT FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such ice prove
TI are not intended or offered for sale.If,however,the building GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or improvement is Sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 IEA) 200 BUILDING USE
builder will have tire . . .
burden of proving that he did not build or im- REB IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to constr¢t 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 dues 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 contmctor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&RC.for this WATER HEATER W/VENT 6.00
reason
Owmert Date ap WATER SYSTEM 5.00 ACC.DATE ACG FILE NO,
WORKER COMPf'NSA ION DECLARATo Or
WATER TREATING EQUIP. 5.00
I h,reby xtt'inm that I have a certificate of consent to sclikinsum' ZONING
m'a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
ropy Ih,rcof(I'" "'Co Lab.C.). yy
policy No Company -Ct d
Q O Certified copy is hereby l g1liih / FIRESPRINK ENEHGYTZ4
Z Z ❑ Certil icd ropy is fled lh the city inspection division. a
MISC.- REFER TO ORD.
O Applicant Y ❑ N V ❑ N❑
w CERTI PICATE,• P EXEMPTI ROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C.
LU > COMPENSATION 1. TRANCE; PLO-CONTR. LIC.NO. PLG.
CL o fThis section need not be completed if the permit is for one TOTAL V❑ N❑ Y,❑ No
::) Z hundred dollars IS 100)or less.)
U O 1 certily that in the performance of the work for which this per, CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL'H mit is issued,I shall not employ any.person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
O i Dale Applicant ALTER OR ADD TO MECH. 5.00
BUILDING
} rn NOTICE '1'0 APPL CANT': If,after making this Certificate of Ex-
.F ? 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=1 F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IQODOC.F.M.) 6.00 SEISMIC FEE
I hcleby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
III porfonnancu of the work for which this permit is ixsurd(Sac. MICROFILM
3097,Civ C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Nance H EATING UNIT(OV ER 100,000 B.T.U.)9.50
Leuder''s Name ELECTRIC lh
1 certify it,.,I hos, .it this application and stme that the above VENTILATION FAN (SINGLE) 4.00
• information is correct. I agree to comply with all city and courtly 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
d 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, costs and expenses which CONST.TAX
may in any way accrue against Said City in consequence of the PERMIT ISSUANCE 10.00
granting of this pe nn it MECH.CONT. LIC.NO. MECH.
T TOTAL TOTAL
u O p it I minae a
INSPECTOR COPY