C8659 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON PERMI NUMBER
BUILDING APPLICATION & PERMIT
\/ ADDRESS
in T 7 l /! ✓ BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
WNER'S PLAN CHECK VALIDATION
.NAME / QTY. ELECTRIC PERMIT FEE
•I`` (1 r. PHONE
NTRACTOR'S
/
NAME q OUTLETS-SWITCHES-RECEP 10.00/1.00
�( /�/ LI C.No. LIGHTING FIXTURES 10.00/1.00
F-O RAcrDR's APPLIANCES-RESIDENTIAL N4.00
ADDRESS / '
PROE�' (j-OS #e PANELS 10.00 DATE OF APPLICATION
OR - PANELS (OVER 200 AMP) 20.00 vLAN CHECK FEE P.c.rvo.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 ^ //
ARMOTORS SEE FEE SCH. J
ADDDDRESSESS
SERVICECHANGE 20.00
w o o LICENSED CONTRACTORS DECLARATIONTEMP.POLE 30.00
F 2
is
1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
Q e, (commureneing with Section 7000)of Division 3 of the Business and r BLDG. ELECT. PLG. MECH.
F w i Professions Code,and my license is in full force and effect
z O m - License Class (� Lic.Number
0,Z F Dale Comraefor
< a =+ �Ln IS, El 11
BUILDING PERMIT
¢ o a a OWNER-Ru1LDIiR DE INFORMATION
E
g d- I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
uoa Law fertile Bellowing reason,(See.7031.5.Boorressand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
r - Code:Any city urcounty which requires upernid t oconstmet,alter,
2 ¢ Q Q improve,demolish,Br repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. �4
D LL requires the applicant for such permit to file a signed statement that _ TOTAL
w m he is licensed pursuant to lire provisions of the Contractors License PERMIT TO
e- i Law(Chapter 9(commencing with Section 7000)of Division 3 oftire nn fq
io Business and Professions Code)or that he is exempt therefrom and OTY- PLUMBING PERMIT FEE r00L
¢ ro file basis for the alleged exemption.Any violation ofSection 703 L5 STORIES TYPE CONSTR.
a ; m by any applicant Ra a permit subjects the applicant to a civil penalty - ALTER-DRAIN&VENT-WATER (EA.) 5.00
L:
of not more than five hundred dollars(S500)J> '
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 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,AR EA,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 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
de himself or I[trough his own employees,provided that such improve-
idealsarenot intended or offered for side.I L however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or ingnovenrvm is sold within one year of completion,tire owner- GAS EASYSTEM OVER 4 IEA) 200
builder will have the burden of proving that he did tint build or ire - . - . .
- BUILDING USE
prove for purpose of side.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ I,as owner of lire properly,Bill exclusively contracting with ❑ ❑ ❑ ❑ 0
licensed contractors to construct 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 does Aft 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 contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec.- ,B.&P.C.fur this WATER HEATER W/VENT 6.00
reason
Owner Dale 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 ofemsenn to self-insure,
or a certificale of Workers'Compensation Insurance,or a certified ZONING _ ENG.SITE NO.
copy thcoof(Sce.3800,Lab.C.).
Policy No. Companyz*�j'q 'o" was- /_
O ❑ Cerlul-d mynll b m;shod. FIRE SPRINK ENERGY T 24
Z Z O t"fi- cop i f vith Sire set insPechon division.
24 App n .w�• MISC.- REFER TO ORD. v N v N�
ir = - E11PT10N PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTIT - LIC.NO. PLG.
Z (Phis secfion need But be completed if file permit is for BeoTOTAL Y❑ NE] Y ❑ NE]
hundred dollars IS 100)or less.)
U O 1 certify that in fire performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
U_ I- frit is issued, I shall not employ any person in any Banner m as to
O U became subject to the Workers'Compensation Laws of California.
¢. Dale Applicam ALTER OR ADD TO MECH. 5.00 BUILDING a6
} lin NOTICE TO APPLICANT: If,after making this Certificate of Ex-.
F. enrption,you should becomesubjecl to the Workers'Comprnsafion APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code,you must forthwith comply with FEE / 7 a 3
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M-) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.EM.) 6.00 SEISMIC FEE 3-U
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Cie C.) HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and stale than the above VENTILATION"FAN (SINGLE) 4.00
• inforn tion is correct. I agree to comply with all city and county PLUMBING
ordinances and stale 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 dmon the
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless file City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way ac against said City in consequence of the PERMIT ISSUANCE 10.00
ranti of this L MECH.CONT. LIC.NO. MECH.
. TOTAL TOTAL
J Ara fArMica4ontractor Dafe
INSPECTOR COPY