C8718 APPLICANT TO FIL�IIN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PE
BUILDING PROJECT I,DENTI FICATIONBUILDING -APPLICATION & PERMIT IT NUMBER
ADDRESS
AOOfl555
r BUILDING - ELECTRICAL-PLUMBING-MECHANICAL8718
•
0INNERP, PLAN CHECK VALIDATION
l� "AQTY. ELECTRIC PERMIT FEE
PHONE
NTRA q'$
NAME J UTLETS-SWITCHES-RECEP 10.00/1.00 e-
(' UO No. LIGHTING FIXTURES 10.00/1.00
ADDRESS PPLIANCES-RESIDENTIAL 4.00
SJ PHONE PANELS 10.00 DATE OF APPLICATION
4�9/
on PANELS
PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE - v.c.No.
ENGINEER
Uc.NO. SIGNS TRANS. 3.00
ARCH.Ess ENG. SPECIALCIRCUIT 5.00 / PERMIT VALIDATION
ZIP TEMP.METER ORtPOLE INS. 20.00 (2.,
-APPLICANT'S 1 C
ADDRESS MOTORS / SEE FEE SCH.
.( SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATION. TEMP.POLE 30.00 Y
e a z w I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
K d (commencing with Section 7000)of Division 3 of the Business and BL E PLG. MECH.
H D z Professions Code,a d my license is in full force and clfect. EJ License Class___Lic.Number
oz oH (Date__�_Con[rvctor - -A
'• ¢_ Y c OWNGR-BUILDER DGCLARA ON<e _ x, r1 BUI. D NG PERMIT
Ko w"' MISC.- REFER TO ORD INFORMATION
g w H I hereby affirm that 1 .n exempt from the Contractor's License t VALUATION $/FT.
oa Low f.Any city owingreywliieSec.703L5.Bosinessand Professions PERMIT ISSUANCE 10.00 � ��
Code.Any mulish a r n pair any structur e p riot t o cons ua n e,also
,
O improve,demolish,or repair any Permit toff prior n Its issuance,also ELEC.CONTR. LIC.NO. ELEC.
w o , requires the applicant for such permit to file a signed statement that - TOTAL PERMIT TO
E
he is licensed pursuant to the provisions of the Contractor's License
' HZQ
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
re r o the basis for the aIle ed exem tion.An
�, g p Any violation of Section 7031.5 ' TORIES- TVP CONSTR.
a3 _ by any applicant for a permit subjects the applicant toe civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).1'.
❑ 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 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 theROq and who does such work FIXTURES-PER TRAP 5.00 $O.FT,FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
ments are not intended or offered for sale if,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 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 that he did not build or ins BUILDING USE
RES
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 ,IND . CON PB Other
ElEl ❑ El' ❑ I,as owner of[he property,am exclusively contracting with
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 not apply
to an owner of propertywho builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
a. contracts fns such projects with a CoutraCIODS)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ l am exempt under Sce. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
S WORK ERS'COMPENSAT'ION DECLARATION WATER TREATING EQUIP. 5.00
1 hemby affirm that I have a certificate of cwlsent to self-insure. ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITENO.
copy(lie f(Sec.3800/Lob.CJ.
Policy��lmpany F._�. (
❑ Cert?m cop hereby u she . -
z Z �Cer�/lif7c�d�"c�op'y� is filed, with the City inspection division. FIRE SPR INK ENERGY T2G
f- 0 cin67-S uJC ,- -T ' MISC.- REFER TO ORD, V ❑ IN Y ❑ N❑
Cr w CBRTIEICATE OF IiXEMPT1ON FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.O.
W > COMPF,NSA7lON INSURANCE PLG.CONTR. LIC.NO. PLG. -
• CL a (This section need not he completed if the permit is for one TOTAL Y❑ N❑ Y[:] N❑
U O h undyed dollars IS 100)or lcss.l
I certify that in the performance of the work for which this per CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL Pile is issued. I shell not employ any person in any omimer so as to
become subject to the Workers'Compenmtion Laws of California,
W
Date, Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} U1 NOTICE TO APPLICANT: If,after making this Certificate of Fx-
F_ Z_ enlption,you should become 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 shall00
be deemed revoked. AIR HANDLING UNIT(TO 10,0C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
.. 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.Civ.C.). H EATING UN IT(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 l Inveouad this application and Sade Hut the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply will,all city and county PLUMBING
ordinances and slate laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
F'
Hereby representativesofthis rp es enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH.
above-mentioned property for ins purposes MECHANICAL
p p Y inspection ur scs.
(WB) agree est save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expCONST.TAX
e •aenses which PERMIT ISSUANCE 10-00
may in any way accruinst said City in consequence of the
aM go(this permj. MECH.CONT. LIC.NO. MECH.
- / TOTAL TOTAL
Iton[ Y�ht et t or
INSPECTOR COPY