8272 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON PERMIT NUMBER
InJILGING APPLICATION & PERMIT
Y� ADDR Ess
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL1 .9 14 Al 8272
Ow R' PLAN CHECK VALIDATION
•'1� ME0 OTY. ELECTRIC PERMIT FEE
NAAMERAcrORs 7 UTLETS-SWITCHES-RECEP 10,00/1.00
T
LC.NO. LIGHTING FIXTURES 10.00/1.00 '
ADDRESS Dna APPLIANCES 4,00
-.` AODREss
PHONE PANELS 10.00- DATE OF APPLICATION
ORcHITEcr PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.No.
ENGINEER
Lie NO. SIGNS TRANS. 3.00
ADDRESS ENG, SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
ADDDRESSDRESS
Ars +g MOTORS SEE FEE SCH.
'F
SERVICE CHANGE 20.00x/
wo o LICENSED CONTRACTORS DECLARATION TEMP.POLE 39=
a o p 1 hereby affirm that I am licensed under provisions of Chapter9 ISSUANCE DATE
yt1Q (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
y z Professions Code,and my license is in full force and effect
z i m o I License Class Lie Number
2 H 0 Date - Contactor
I
'aBUILDING PERMIT
¢ a OWNER-BUILDER DECLARATION
M
o a U INFORMATION
X 1 hereby affirm that 1 am exempt from the Contractors License MISC.- REFER TO ORD
LLD ¢ Law for the following reason.(Sec.7031,5,Businessand Professions ' pERMIT ISSUANCE 1,0,00 r VALUATION $/FT.
Code:Any city or county which requiresa permit to construct,alter,
¢ ¢ < 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. r•• LIC.NO. ELEC.
a w m ¢ requires the applicant for such permit to file a signed atatemenl that TOTAL a PERMIT TO
. he is licensed pursuant to the provisions of the Contractor's License
rz.5- Law(Chapter 9(cmann mgwithSection 7000)of Division 3 of the
5 4 o Business and Pohfe,.mrs Code)or thathe is exempt therefrom and QTY. PLUMBING PERMIT FEE
ec I- o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a ; `_° by any applicant for a.permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more tan five hundred dollars($500T):
❑ 1,as owner of the property,or my cmployeee with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,unit the slmclem is not s
intended or offered for sale(SIS. 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 sn FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that-such improv
mints are Get intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 1 NC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 200
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 RES IND CON PR Other
w
❑ I,as oner of the Property,am exclusively contracting with . .
❑ ❑ ❑ ❑ ❑
licensed contractors to construct (he pHjeel(Sec. 7044,Business LAWN SPRINKLERS- I INC 5 V.B. 6.00 ASSESSORS PARCEL N0.
and Professions Code:The Contractor's 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 contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ I am exemptunder See. ,8.&P.C.for this WATER HEATER W/VENT 6.00
\ asin
Owner, )ate WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATIA DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure.
or u certificate of Workers'Compensation Insurance,or a certified 20NING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished.
FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is tiled with the city inspection division. MISC.- REFER TO ORD.
O Applicant YE] N� v � N�
~ rn PERMIT ISSUANCE 10.00
� - CEk'I'IFICA'Ifi OF EXEMPTION FROM WORKERS' ELoODzoNE A.L.U.C.
W > COMPENSATION INSURANCE PLO.CONTR� LIC,NO. PLG. y N V N
Q. O (This section need not he completed if the permit is for one TOTAL
EI
Z) Z hundred dollars(4100)or less.)
U O I certify that in the perfornhance Of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
W 1- mit is issued,1 shall not employ any person in any manner so as to
0 become subject to the Workers'Compensation Laws of California
WDQ. ale Applicant BUILDING
} w NOTICE TO APPLICAN"f: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
1.._ Z cmptiorh.you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply fit,
FEE
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IQOODCEM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performmnce of the work for which this permit is issued(Sec. MICROFILM
3097,CIZ.(..), HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Add. HEATING UNIT(OVER 100,000 B.T.U.)9.50 /
Lenders Name
ELECTRIC
I certify that 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-COMM 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 (GVBf 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to are, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses whichpERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
anting of this permit. MECH.CONT. LIC.N0. MECH.
\ TOTAL TOTAL
IKI I n[ ntrac Date
INSPECTOR COPY