8753 r
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDINGAPPLICATION & PERMIT 8753
7 ADDRESS
le-XL BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER' 3 1
PLAN CHECK VALIDATION
•'1 NAME QTY. ELECTRIC PERMIT FEE
NAAMERACTORs UTLETS-SWITCHES-RECEP 10.00/1.00
LIC,No. LIGHTING FIXTURES 10.00/1.00
r,0 R
CONTRASRESS PPLIANCES-RESIDENTIAL 4.00
PRONE _ PANELS 1 ,00 DATE OF APPLICATION
RcertecT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
O
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENG' SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
Ars
ADDDRESSDRESS MOTORS SEE FEE SCH.
ter' • SERVICE CHANGE 20.00
wo o f LICENSED CON'T'RACTORS DECLARATION TEMP.POLE 30.00 /
v hhereby affirm that I am licensed under Provisions of Chapter 9 - ISSUANCE GATE
ya $ (cimtmencing with Section 7000)of Division 3 of the Business and BLDG ELECT. PLG. MECH.
Z 0 m Z Professionsla Code,one_ I my license is in full tome a c�c0 ❑ ❑ ❑
O T O Lot, Class�J�,)z��Cio.Number
9 Z DalcQnamdor
m ¢ a OWNER-BUILDER UILDfiR DECLARATION , � BUILDING PERMIT
_ c ,a INFORMATION
D REFER TO ORD
w 3 LL w 1 hereby affirm that I am exempt from the Contractor's License MISC.- I VALUATION $/FT.
F LL m j Law for the following reason(Sec.7031.5,Ilusiness and Professions pERM1T ISSUANCE 10.00
m� Code:Any CLL Or county which requires a permit L.c.uw rucL alter, V,- o
IE a p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. p LIC.NO. ELEG e(..j C)G�
a w C e requires the applicant for such permit to file a signed statement that 71 ' rl`L TOTAL PERMIT TO
he is licensed pursuant to the provisions of the Contractors License
H Z i Law(Chapter9(commencing with Section 70001 of Division Sof the AI' i r ��
<
Business and Professions Code)or that he is exempt Therefrom chid QTY. i PLUMBING PERMIT FEE
It the basis for the alleged exemption.Any violation of Secllon7031S P S ORT PECONSTR.
w. by any applicant for a permit subjects the applicant tea civil penalty. ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($5000.):
❑ L as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP -RES.UNITS
intended
sole compensation,will do the work,and the structure is not
in«nded o'r'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 sechwork FIXTURES-PER TRAP 5.00 sD.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improde-
mentsarenotintendedorofferedforsalelf,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 ) 200 BUILDIN usE
builder will have the burden of proving that he did nut build or im - . . RES IND PB Doer
pnrvc for purpose of sal,.L n nlruINDUSTRIAL WASTE INTER. 30.00
13I,as owner of the property,am exclusiJelyecocHng with ❑ ❑ N1 ❑. ❑
licensed contractors to construct the project ISee. 7044, Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESS0 P RCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or impro0cs thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractoessi licensed pursuant to
the Contractor's License Law, SEWER-SAN ITARV-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ Iamexemptunder Sce. 7_,B&P.C.burtIr, WATER HEATER W/VENT 6.00
reasmn
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
- 14
t WORKERS'COMPENSATIOOpN DECLARATION WATER TREATING EQUIP. 5.00
1 hereby turn, that I have a cert Mate of consmn to set(-insure.
\' or u certificate of Workers'Compen5a(ion Insurance,or u ce'tific ZONING ENG.SITE NO.
V copy thereof(Sec.3800.Lab C.)(\ I'
Policy No. Company. 1.
O ❑ Certified copy is hereby Wiliished. FIRE SPRINK ENERGY T 24
z Z Certified copy is fled with the city inspection MISC.- t REFER TO ORD.
O� `A(Splicanlc�_!_!_ e V❑ N❑ V ❑ N❑
CC y CE RTI F ICA'T E OR E. iM ,ION FROM w'ORKIiRS PERMIT ISSUANCE 10.00 a000 zorvE A.L.0 C.
LL > COMPENSAT10N'INSURANCI> PLG.CONTR. LIC.NO. PLG. ❑ E] [:] O
CL o ('Phis section need not N 4,dc ed if the m6nit'•is for one ✓'� •�z TOTAL Y N V N
ZE Z hundred dollars IS 1001 or lccc.l 1S,
U O 1 certify that in the perior n of the work for which this pc�-'QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued, I shall not employ anY person in any manner so as to
U become subject to the Workeri Compensation Laws or Card6rnia.
ED Date Applicuni ALTER OR ADD TO MECH. 5.00 BUILDING
} rn NOTICE TO APPLICANT: If,after making this Certificate of Ex-
Z emption,you should become subject to lire Workers'Compensation APPLIANCE 5.00 PLAN CHECK is i o
provisions of the Labordode, you most forthwith comply with V
FEE 71
0 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 I0)000C.F.M.) 6.00 1SEISMIC FEE
1 hereby ofErm Ithat there is o construction lending agency for f� EXHAUST HOOD(WITH DUCT) 5.00
the performance of°tlm work In,which this Permit is issued(Sec. MICROFILM
3097,ON C.). HEATING UNIT(TO 100,000 B.T.U.) 0.00 / I
Lender's Name
7.
Lender's AddreHEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC. I f
ss
I certify that I have read this application and stutcihat the abovz VENTILATION FAN (SINGLE) 4.00 11F) r 1
information is correct. 1 agree to comply with all if and county 4PLUMB ING { '
ordinances and state laws relating to building construction, and B01LER-COWlI (H.P.or100,000B.T.U.) 6.00 ,
hereby authorize representatives of this city to enter upon the r) '
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 RTU)SEE FEE SCH. [ MECHANICAL
(We) agree to save, indemnify and keep Ilannlcss the City of MISC.- REFER TO ORD.11 N '
Cupertino against liabilities,judgments, costs and expere,which PERMIT ISSUANCE ( s'r . .� IL 10.00 CONST.TAX
may in any way accrue against said City in consequence of the -+
granting of this permit. MECH.CONT! ') s j,LIC.NO* )' '- MECH.
A/ N 4,_ TOT
TOTAL
Si lu APP¢ant/Co ¢or s1`.,
INSPECTOR COPYo
`
�,trn I