C8177 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
EDILDING APPLICATION & PERMIT
ADDRESS �J�'f
BUILDING-ELECTRICAL-PLUMBING -MECHANICAL Al ! 7
a 1 7
OWNER' RIA CHECK VA LIDATION
"AME y_Q. !�V OTY. ELECTRIC PERMIT FEE
CGNTRgCTOR'S
rvAMElele0.rej dotWorl� OUTLETS-SWITCHES-RECEP 10.00/1.00
s -I' 1e
r'I
TI C.No. LIGHTING FIXTURES 10.00/1.00
CONTA ops
ADDRESS APPLIANCES-RESIDENTIAL 4.00
ADD
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC,No. SIGNS TRANS. 3.00
ADDRESS ENE. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. 20.00
APPLICANT s MOTORS SEE FEE SCH. T
ADDRESS
S -, 0 SERVICE CHANGE 20.00 Q
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
u I hereby affirm Ilml I am licensed under provisions of Chapter,9 ISSUANCE DATE 1
a 0.ronuncHeing will, Section 7000)of Division 3 ol'the Business and BLDG. ELECT. PLG. MECH.
m i Professions Codc,and my license is in Cull force and effect. ❑ ElElElz o w - License Class Lie Number
9 w w Date Contractor
m E " BUILDING PERMIT
It m4 OWNER-BUILDER DECLARATION INFORMATION
w
;LL to I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION $/FT.
u o a Law for the following reason.(Sec 7031.5,Business and Professions PERMIT ISSUANCE 10.00
in Codc:Anycityurcounty which requires a permit to construct,alter, /tire
EE a,¢O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
LL requires the applicant for such permit to file a signed statement that - TOTAL PERMIT TO
F:
At he is licensed pursuant to the provisions of the Contractor's License
Uzi Law(Chapter 9(commencing with Section 7000)of Division 3 of the
< Business and Professions Code)or that lie is exempt therefrom and QTY. PLUMBING PERMIT FEE RCS?-9,rQ 43.97,1<,d NW
r G
the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
o ; � by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(SSOOL): -
❑ 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
Codc:The Contractor's License Law does not apply to an owner of
property who Ito llds Or improves thereon,and who does such Wolk FIXTURES-PER TRAP .00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees,pe,if,however,wive such inhprove-
hicrosumnolintendcdoroffmcoyeesala.lf,ed thatsthe building GAS-EA.SVSTEM-11NC.40UTLETB 6.00
or improvement is Sold within one year of completion, - . .) 2.00[tier owner- GAS EASYSTEM-OVER 4 IEA
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(See.7144,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 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.
❑ l at,,exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
azon �
Owncir ` ia - D; WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO,
WORK IiBB'COMI'fiNSAT10N DGCLn RATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.CJl -
Policy No. Conrlrusry -
O ❑ Certified Copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y ❑ IN Y ❑ N❑
N C I?BTI F I CAI'1:01'Ii X lz M PT ION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C.
LU > COhIPENSATION INSURANCE. PLG.CONTR. LIC.NO. PLG.
�
Z( This section need nut be completed if the permit is for one TOTAL Y❑ N❑ Y E] N❑
hundred dollars IS 100)or Tess.)
U O 1 certify that in the performance of the work Iso which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in any mannerso as to
U become subject to the Workers'Compensation Laws of California.
0 C.W DateApplicam ALTER OR ADD TO MECH. 5.00 BUILDING /Q
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F ? cmption,you should become subject to the Worker,'Compensation APPLIANCE 5.00 PLAN CHECK
provisions-of the Labor Code, you most Hwhwilli comply will, FEE
U such provisions or this Per nhit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONST RUCTION 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 3097.Civ.C.)n`e of mMICROFILM
e work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's AddreHEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
ss
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
® inlo1nialion is correct. I agree to comply with all city and county PLUMBING
ord tancCs and State laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby action, representatives of this city to enter upon the BOILER-COMP Inver 100,000BTU)SEE FEESCH. MECHANICAL
above mentioned properly for inspection purposes.
(we) agree to save, indemnify and keep harmless 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 accrue against said City in consequence of the '
granting Of this permit q MECH.CONT. LIQ NO. MECH,
r l�]f su TOTAL TOTAL
/ Sign td o App iCniHi ontro ctor D e I ✓-
U INSPECTOR COPY