8450 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFI N I PERMIT NUMBE
ILGING APPLICATION & P.'IlT -----------
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BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 't
OW EP's PLAN CH ECK'VALI DATIO
NAME (q'OS) OTY. ELECTRIC PERMIT FEE I'
• ' V'I.A i✓'L'1 ML-SSS-PHONE 7
NANERAcroRs UTLETS-SWITCHES.;RECEP 10.00/1.00 �il
H uc.rvo. LIGHTING FIXTURES 10.00/1.00
rorvrRAcroR's
_ � � PPLIANCES-RESIDENTIAL 4.00
Ai <14f-�02%2io FPHONE PANELS 10.00 DATE OF APPLICATION
AopREss (401
J22
AHm
L. OR HI PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE
ENGINEER
LIC.No. SIGNSTRANS- 3.00
ADDRESS ENa SPECIAL CIRCUIT 5.0Q PERMIT VALIDATION
zm EMP. METER OR POLE INS. 20.00 I I I��
APPLICANTS MOTORS SEE FEE SCH.
aooREss
}' SERVICE CHANGE 20.00
w 0 9 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
¢ 0 U I hereby affirm that 1 am licensed under provisions of Chapter 9 ISS
m a w UA E A E
(commencing with Section 7000)of Division 3 of the Business and BLDG. ELEC PLO. MECH.
F w z Professions Code.and my license is in full force and effect.
Q i m o License Class g H Lie.Number
H Date Contractor
I BUILDINERMIT
¢ ¢o i t OWNER-BUILDER DECLARA'T'ION INFOR ATION
wr I hereby affirm that 1 am exempt from the Contractors License MISC.- REFER TO ORD
¢ ¢0 j Law for the following reason.(Sec.7031.5.Business and Professions VALUATION / S/FT.
H - .PERMIT ISSUANCE 10.00 /
Code Any city or county which structure permit toconstruct,.also
Q R ¢o improve,demolish,or repair any slimmer,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC.
mLL requires the applicant for such permit m file a signed Statement that 1' TOTAL
d whe is licensed pursuant to the provisions of the Contractor's License
H z i Law(Chapter 9(commencing with Section 7000)o(Uivision 3 ofthe
P Y a Business and Professions Code)or that he is exempt therefrom andQTY. PLUMBING PERMIT FEE
¢ H o the basis for the alleged exemption.Any violation of Sermon 7031.5 ,Y STORIES TYPE CONSTR.
m by any applicant for a permit subjects the applicant toa civil penalty
of notmore than five hundred dollars(S500).): ALTER-DRAIN& VENT-WATER (EA.) 5.00
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC. ROUP RES.UNITB
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 License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP S.00 SO.FT.FLOOR AREA TOTAL ACREAGE
y• himself or through his own employees,provided that such improve
rents are not intended or offered for sale.If.however,[lie building GAS-EA.SYSTEM OUTLETS 6.00
or improvemmut 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 build or Ira- BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RE IND CON Pa Other
F ❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ;ASSESSOgS PARCEL NO.
and Professions Code:The Contractor
s License Law docs ,of 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 sminactmto licensed pursuant to t;l
slimmNP.
er,',License Law. SEWER-SANITARY-STOREA.200ft/10.00 TRACT NO. PARCEL NO,
Iamexumptundcr Sec. ,B.&P.C.for this WATER HEATER W/VENT^^ 6.00 e
ort
Owoen Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORT:ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have u certificate of consent to sell'-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
ScIpy-themof(Sec.3800,Lab C.).
,1'ol¢y NO. ompany
. .0 `-Td-Certilicdc p ¢hereby furnish d. FIRE SPRINK ENERGY T.24
F ZO ,�❑-Cel ificA l is lila wit the city-inspection division. MISC.- REFER TO ORD. Y N Y N
� A li an ❑ ❑ ❑ ❑
E FICA'TE O P E X LM PTI ON F ROM WO R K Ii RS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
IU > COMPENSATION INSURANCE PLG.CONTR. ❑C.NO. PLG.
Z (This section need-not'be'rompleted if the permit a for one TOTAL Y[:] N❑ Y E] N❑
hundred dollars($100)or less.) 11
U O I certify that in the performance of me work for which this,per-, QTY. MECHANICAL PERMIT FEE FEE SUMMARY
-
TEL 1- mit is issued,I shall not employ any person in any manner so as to
O w hucomc subject to the Workers'Con.pensutiun Laws of California ^
O_ Dan Applicant ALTER OR ADD TO MECH. 5.00 -BUILDING
} to NOTICE 131'A PPLIC NI': If,a to making this crti icutc of Ex-
F.. Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith connply with FEE
U such provisions or this permit shall h"deemed revoked' AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
- CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10SMC.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
'P• the performance of the work for which this permit is issued(Sec. MICROFILM
t 3097,CN C.), HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Address
HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's AAJss ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 -
information let
correct., ugrcc to comply with all city and county - BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
oil:..anti•, isisJ smte laws relating to building construction, and
hereby authorize representatives of this city to enter upon the
14
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep Inannless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
'd
may in any ay accrue ago' City' in consequence of the
granting IF spermiLMECH.CONT. LIC NO. MECH.
TOTAL TOTAL ��
a Sig ' I Applic til/Co o U' e
!'
INSPECTOR COPY
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