8416 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
�- J BUILDING - ELECTRICAL-PLUMBING-MECHANICAL8416
OWNER'S PLAN CHECK VALIDATION
NAMEZV A OR'S ( QTY. ELECTRIC PERMIT FEE
PHONE -
ONL
NAME UTLETS-SWITCHES-RECEP 10;00%1.00 i
LIC.No. LIGHTING FIXTURES 10.90/.1,00
ADDRESSTo PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 - DATE OF APPLICATION
ORRCHITsci PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE D.C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRESS EN SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT MOTORS SEE FEE SCH.
ADDRESS
E
SERVICE CHANGE 20.00 '/ y i
°¢ TEMP.POLE 30.00
Hoo LICENSED CONTRACTORS DECLARATION
<i w i hereby'affirm that I am licensed under provisions of Chapter 9 t L ISSUANCE DATE
in a H (Commencing with Section 7000)of Division 3 of the Business and - BLDG. ELECT. PLG. MECH.
r m z Professions Code,and my license is in full farce and effect. ❑ ® ❑ ❑
0 w License Class Lic.Number
m Huo Date Contractor
BUILDING PERMIT
¢ ¢ w a OWNER-BUILDER DECLARATION
a o a INFORMATION
wg LL N I hereby affirm that I an exempt from the Contractor's License MISC.- REFER TO ORD
u O a Law for the following reason.(Sec.7031.5,Business and Professions VALUATION $/FT.
r - 4 PERMIT ISSUANCE ,•p,pD,
Code Any city or county whichregtliresa Permittoconstruct,alteq
¢
Or a 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTH. LIC.NO. ELEC. s
va
O¢ requires the applicant for such permit to file a signed statement that TOTAL �.
a w$m he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
HZQ Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
4 D Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ H m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES I TYPE CONSTR.
dam _ by any applicant fora permit subjects the applicant toacivilpenalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(8500).):
O I,as owner of the property,or my employees with wages as BACKFLOW PROTECT. DEVICE 4.00 DCC.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,AR EA,COND. 5.00 '
Code'The Contract.,',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 SO,FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve.
ments are not intended or offered for sale.IL however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
Of improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4(EA.) 2.00
builder will have tile - . - .
e burden of proving that he did not build or int- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 RES IND CON PB ,.other
El 1,as owner of the property.am exclusively contracting with . .
❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professi.ns Code:IThe 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 fur such projectswitha contractoAs)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Conlmttor License Law. TRACT NO. PARCEL NO.
❑ I um epi undc eve ,B.&Poco for this WATER HEATER W/VENT 6.00
Re.l.
N/ Owner Date WATER SYSTEM 5.00 aCc.OnTE ACO.FILE NO.
^\ WORK.RS'COMPI:NSA'I ION DECLnRn'I'lo WATER TREATING EQUIP. 5.00
77
1 hereby affirm that 1 have a certificate ofconsent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lub.CJ.
Policy No. Company
O ❑ Certified copy is hereby furnished.
FIRE SPRINK ENERGY T]4
Z Z ❑ Certified copy is fled with the city inspection division. MISC.- REFER TO ORD.
� O Applicant v ❑ N❑ Y ❑ N❑
CrN CIiforw[CATEOF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L,II.C.
LU > COh1I'l1NSA'f1ON INSURANCI' PLG.CONTR. LIC.NO. PLG.
CL O 1'rhis section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
:3 Z hundred dollars IS 100)or less.)
U O 1 certify that in the Perfurnidnee.f 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
O w become subject tothe Workers'CompensationLaws ofCalifornia.
GO. Date Applicant BUILDING
>_ W NOTICE '10 APPLICANT: If, Her making this Cutificate ulEx- ALTER OR ADD TO MECH. 5.00
F Z emption,you should become subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK
pruvisions
siof the
lLabor Code, you must forthwith comply with FEE
permit shall be decomd revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONST RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE
I hereby ul'finn that Ileo, is construction Icn ling 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
Conder',Address HEATI NG UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
1 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 sale 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
above-mentioned property for inspection purposes. BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indenmily and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses Polo-
may in any way accrue against said City in consequence of the
granting of this permit. MECH.CONT. LIC.NO. MECH,
TOTAL TOTAL
Signature of Applicant/Contractor Date
INSPECTOR COPY