8342 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIF[CATION - PERMIT NUMBER
yDILDIN APPLICATION & PERMIT 8342
ADDRESS
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER S PLAN CHECK VALIDATION
/.NAME QTY. ELECTRIC PERMIT FEE
•
NRS PHONE
11/11
AME C.-10 UTLETS-SWITCHES-RECEP 10.00/1.00
Ic.No'd. FIXTURES 10.00/1.00 -�
MN N RACT APPLIANCES-RESIDENTIAL 4.00
z ADDRESS
PHONE4&31-0
PANELS 10.00 DATE OF APPLICATION
ARCHITECT ' PLAN CHECK FEE P.C.N0,
OR Horton 411, ; Q PANELS (OVER 200 AMP) 20.00
ENGINEER J
TIC.No. SIGNS TRANS. 3.00
AARCH OR DDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
,00 ICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 T 0
a u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
H z n (commencing with Section 7000)of Division 3 of the Business and
¢ BLDG. ELECT. PLG. MECH.
F m i Professions Code,and my license is in full force and effect ❑ ❑ ❑ ❑
{iO
o i w o License Class C-/•p ontmctor Number
I7W
e- .�Co '-"' 1'
er �Z E /" BUILDING PERMIT
IS ¢ ¢ OWNER-BUILDER DIiC ION
o a " MISC.- REFER TO ORD INFORMATION
w ; N I hereby OUR, that I am exempt from the Contractor's License
LLOj I.aw Forthcl'ollowinyreasom(Sec.7031.5,11ohn ess and Professions PERMIT ISSUANCE ��Q VALUATION '$/FT.
� - Code:Any city orcounty which requiress permit toconstruct alter,
¢ Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
D ¢ requires the applicant for such permit to file a signed statement(hat TOTAL (� PERMIT TO
A w m o he is licensed pursuant to tire provisions of He Contractor's License
>
Law(Chapter 9(commencing with Section 70000of Division3ofthc
< Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE R/- ,`E,1,`E,1 GB.
f i o
¢ H o the basis for the alleged exemption.Any viola(ion of Section 7031.5 STORIES TYPE CONSTR,
by any uPplicanI
for a permit subjects the applicanto a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than Iive hundred dollars(5500).):
❑ 1,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 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 does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that suchimprove-
mous are not intended or offered for sale-11.however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement Is sold within one year of completion, the owner- -GAS EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving than hu did not build or int- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND eoN Pe Omer
131,as owner of the property,a ra
exclusively contcting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and I'rafessions Code:The ContmCtor's License Law does not apply
f to an owner of property who builds m improves Dmrsron,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a conime(or(s)licensed pursuant In SEWER-SANITAR V-STORM EA.200ft/10.00
- the Contractor's License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
retsul
1 Owner Data WATER SYSTEM 5.00 ACC.DATE ACO.FILE NO,
WORK ERS'CONIPENSATION DECLARATION WATER TREATING EQUIP. 5.00 -
1 hereby affirm that I have a certificate of consent to Self-Insure. ZONING
P,
a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Pol icy No. ��Company -�
0 11CL'rta��¢¢ropy is hereby' IS ILd. C 1 I FIRE SPRINK ENERGY T-24
Z Z ❑ Certifud copy is filed with he BY t 1. MISC.- REFER TO ORD.
O App11C:111(_ Y ❑ N❑ Y ❑ N
PERMITISSUANCE 10.00
LL C-H 'I'l17ICA'1'801'Exi MP ION'FROM WO R K F RS' FLOOD ZONE A.L.U.C.
W > COhIPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. v❑ N❑ v ❑ N❑
= Z (This section need not be completed if the permit is for one TOTAL
hundred dollars IS 100)or less.)
U O I certily that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I shall not employ any person in any manner ,,as to
become subject to(he Workers'Compensation Laws of California.
W Dam Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} DO NOI'ICF 'f0 APPLICANT': If,after making this Certificate of Ex-
F 2 clnp(ion,you should become subject to(he 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=C.F.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the perlbrmmnce of the work 1'or which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender',Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lenders Address ELECTRIC (fO
I certify that l have read this application:old state that the above VENTILATION FAN'(SINGLE) 4.00
information is correct. 1 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 authorize representatives of this city to Corer upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harritess the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way acave against said City in Consequence of the
granting of this perm(. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
�( S na u c oI p Ii II/ omrac or Da
INSPECTOR COPY