8570 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
APPLICATION & PERMIT
ADDRESSILDING 8570
' aooBEss '
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWN PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
PHONE
rvAMERacrORs UTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00 F
CONTRACTOR imps
ADDRESS PPLIANCES-RESIDENTIAL 4.00
CONTRA
HONE PANELS 10.00 DATE OF APPLICATION
onnCNrtEci PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.bNO.
ENGINEER
uc.No. SIGNS TRANS. 3.00
AARCH.OR DDRESS ENG SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 ,t
APPLICANTS
ADDRESS MOTORS SEE FEE SCH. K /
SERVICE CHANGE 20.00 r
0 0 0 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
¢0 w 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
m G w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.'
H m z I'rofessions CodenJ ease is in full force and effect ❑ 1�I
Z, o w - License Class i Lic.Number El ❑
F ut _ J
0 t H wt [)are�K 2 <T-Oe"" Contractor �'l
7-
A OWNER-BUILIUICLARATION F� BUILDING PERMIT
¢ INFORMATIONo i
w3 LL H I hereby affirm that I an,cxenlpl from the Contractors License MISC.- REFER TO ORD
u 0 j Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
' � - Code:Any city orcounty which re(luiresa permit teconstruc t,ulter,
¢ 2 ¢ FO improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.Nr, ELEG.
y c M requiies the applicant for such permit to file a signed statement ilia( TOTAL PERMIT i/0 '
u w m he is licensed pursuant to the provisions of the Contractor's License
HiQ
Law(Chapter 9(commencing with Section 7000)o'Division 3 of the M
g 4 0 Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
(c H m the basis for the alleged exanption.Any violation of Section7031.5 STORIES TYPE CONSTR.
Ate - by any applicant for a permitsubjects the applicant to a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars(S500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the st ructme is not
intended or oPfcovd for sale (See 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law docs not apply to art owner ul
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
meatsre through his awn employees,for s le,If.ho that such inlpnrvc-
mmselfo notintendedemployer,poli ed that suherilmovg GAS-EA.SYSTEM-1INC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-.EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or im- - BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER3000 EEs IND CON PB Omer
. .
0 I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,BusinessLAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractors License Law docs 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 contractods)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO, PARCEL NO.
0 Iamexemptunder Sec. .B.&P.C.for this WATER HEATER W/VENT t 6.00
reaSall
Owner Data WATER SYSTEM ' 5.00 ACC.DATE ACC.FILE NO,
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofconsent to self-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3400,Lab.0).
Policy NoompmryHj-?.
O 0 Car ed opy'is hereby fuuniss,ed� r_ FIRE SPRINK ENERGYT24
z Z p�..CerlifieJ ropy is fled i(h the ity inspection Jivisiml. '
0 n�ilic:ul(T(y�z_ I�a�Lh>_'��_� f / (j{� MISC- REFER TO ORD. Y ❑ N❑ Y ❑ N❑'
� m CERTIFICATE 017Ii XEMPFION FR(SM WORKERS' PERMIT ISSUANCE 10.00 FLOOD$ONE A.L.U.C.
LD > ,M COMPENSATION INSURANCE PLG.CONTE. LIC.No. PLG.
CL a (Phis section need not he completed if the permit is for on, TOTAL Y❑ N❑ Y❑ N❑v
::) Z load red dollars(S 100)nr Icv.)
U 0 I certify hit in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued.I shall not employ any person in any manner su as to
00 become subject to the Workeri Compensation Laws of California. BUILDING
a Ua(c Applicant ALTER OR ADD TO MECH. 5.00
} tD NOTICE'10 APPLICANT: If,after making this Certificate of Ex-
f- Z emp(ion,you should Delmore 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 10,000OF.M.) 4.00
CONSTRUCTION 1.1'AIDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I Icreby,affirm (hat (here is a construction lending agency f)Ir EXHAUST HOOD(WITH DUCT) 5.00 ,
the performance of the work lin which this permit is issued(Sec. MICROFILM
3097.Cre.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certify (hal l 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-COME(3 H.P.Or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the B /OILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL ,
above-mentioned property for inspection purposes. 1
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expanses which CONST.TAX
nmy in any way accrue against said City,in consequence of the PERMIT ISSUANCE 10.00 in tl
granting fill permit. ECH.CONT. LIC.NO. MECH.
_ TOTAL 7� TOTAL
I Signatur Ppll n o c In af,,LI
T
INSPECTOR COP