8318 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - LISE.BALL POINT PEN ONLY
RMIT NUMBER
BUILDING PROJECT IDENTIFICATION BUILDING APPLICATION & PERMIT
aoOREss e
' n BUILDING-ELECTRICAL-PLUMBING-MECHANICAL8318
OwrvE - PLAN CHECK VALIDATION
NAME _ OTY. ELECTRIC PERMIT FEE
•
7 4 PNON
CONTRACTOR
s /� UTLETS-SWITCHES-RECEP 10.00/1.00
Ci L.' uc.NO.o LIGHTING FIXTURES 10.00/1.00
ADDRESS ons " PPLIANCES-RESIDENTIAL 4.00
CONTRACTOR
e. PHONE _ PANELS 10.00 DATE OF APPLICATION_
ORC"IT ECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE - P,C.N0.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRESS ENI' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
zlv TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
AOORESi
SERVICE CHANGE 20.00
wa LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 (f's
Q o U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w "' (commencing with Section 7000)of Division 3 of the Business and
a m BLDG. ELECT. PLG. MECH.
F w z Professions Code daI' use is in full fob and of cc II�`'�
2 o m - License Class Lia Number Jt'
9 m = Date f�ut. setae J'e'
a r BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DECLARATION
A o a u INFORMATION
w 3 LL w I hereby affirm Out I ani exempt from the Contractor's License MISC.- REFER TO ORD
¢ og Law liar the followinghcason.(Scc.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
- Code:Any city or comity which requiresa permit to construct,alter,
¢ ¢ p improve,demolish,or repair any stricture,prior to its issuance,also ELEC.CONTR. LIG NQ ELEC. ,
a wO u requires the applicant for such permit to file a signed sutement tial TOTAL PERMIT,TO
m he is licensed pursuant to the provisions of the Contractor's License
i Law(Chapter 9(commercing with Section 7000)of Division 3 of the // �
io Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE �' U'-�
¢ r o the basis for the alleged exemption.Any violation OfSection 7031.5 STORIES TYPE CONSTR.
a 3 m by any applicanl for u permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more tun five hundred dollars(S500).):
Cl 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 strt comic 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 docs such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
- • himself or through his own employees,provided that such improve- r
idents 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, - . -OVER 4(EA.) 2.00 the owner- GAS EASYSTEM
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). RES IND CON PB Other
❑ 1,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 0 ❑ O 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 dues 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 contractors)licensed pursuant to SEWER-SAN V-STORM EA.200tt/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
rea❑sonl am exempt tinder Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
l hereby affirm that l have acertificate ill consent toself-insure' ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
e.PY)her S`y•�,3y 0,,Q b
O Po c v S a
I li le c P ss ll}}•.. a"fu- shL FIRE SPRINK ENERGY T 24
Z Z Q�Certificd copy i 1'd the ty inspection division.
O A/pfR IH /l�akC, 0 MISC.- REFER TO ORD. Y NE] Y ❑ IN
C N CE KT'I I I CA'1'1:OF 1:X I7M P'I'I ON I'ROM WORKERS' PERMIT ISSUANCE !D= n FLOOD ZONE A.L.UC.
W > COMI'IiNSA1'ION INSURANCE PLG.CONTR. LIC.NO. PLG. /e Y N Y N
EL Q (This section need not he completed it the permit is for one TOTAL
his
O hundred dollar,(S 100)orleasI
certify that in the performance at the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall not employ any person an ny manner sit us to
Ow become subject to the Worker Conhpensation Laws of Culifortim
Lu Date Apphe:mt BUILDING
>_ h NOTICE 'LO APPLICANT: D,alter making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
Z_ onnPtion,you should become subject to the WorkersCompensation 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=11F.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIRHANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that then is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
,the performance of the work for which this permit is issued(See MICROFILM
3097,Civ.C.L 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 have read this application and slide thin the above VENTI LATION FAN (SING LE) 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-COWI3H.P.or1OO,000B.T.U.) 6.00
hereby autlwrize represcnmtives of IRS 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 Imrmless 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.acttcme against said City in consequence of the
granting Min ermt MECH.CONT. LIG NO. MECH.
/S TOTAL /�=
+T�- a �- TOTAL
Signa reo Appi nlf Lontracor -�-mate
INSPECTOR COPY