8458 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY/
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
ADDRESS . APPLICATION & PERMIT ��
aooREss 1.11611
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
ONE
NAME °R5 OUTLETS-SWITCHES-RECEP 10.00/1.00
uc.No. LIGHTING FIXTURES 10.00/1.00
ro RAcroR's
aooREss APPLIANCES-RESIDENTIAL 4.00
S S
PHONE PANELS 10.80 -(/V DATE OF APPLICATION
OHCHIr PANELS (OVER 200 AMPI 20.00 PLAN CHECK FEE P.C.NO,
ENGINEER
LIC NaSIGNS TRANS. 3.00
ADDRESS ENG _ SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
zlv ` EMP.METER OR POLE INS. 20.00
Avvucarvrs
ADDRESS MOTORS SEE FEE SCH. W
SERVICE CHANGE 20.00
'00 LICENSED CONTRACTORS DECLARATION TEMP.POLE 1 30.00
G Z U 1 hereby affimt that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
< m (commencing-with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F w z Professions Code,and my license is in full force and effect. ❑ ❑ O
z o,�- License Class=y o-Lie.Number
o wJD DatcConUamor
a r E BUILDING PERMIT
¢ ¢ ¢ OWNIiR-BUILDER DE CLA ATION
a u INFORMATION
o
X gam 1 hereby affirn that I am exempt from the Contractor's License MISC.- REFER TO ORD
LL o ¢ Law for the following reason.(Sec.7031.5,Businessand Profiessimu VALUATION
Code:Any city or county which requiresa permit to construct alter, PERMIT ISSUANCE " 108 d-o
rt ¢ ¢ improve,denmlish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEG.
a wO LL Imryirex the applicant for such permit to the a slimed statement that TOTAL PERMIT TO
w w be is licensed pursuant to the provisions of the Contractor's License
rZ > Law(Chapter 9(commenciagwith Section 7000)of Division 3 of the ELE�.•7
4 Business and Professions Code)or that he is exempt therefrom and QTY, PLUMBING PERMIT FEE
¢ r 0 the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR:
La by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars(S500t): ALTER-DRAIN& VENT-WATER (EA.15.00
❑ 1,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 thereon,and who does such work FIXTURES-PER TRAP 5.00 so.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees.provided that such improve-
' mems are not intended or offered for sale 11.however.the building GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, - . - . .00(lie owner- GAS EASYSTEM OVER 4 (EA ) 2
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). r INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Ome,
❑ I,as owner of the 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: I'lie Contractor's License Law docs not amply
to un nwner of property who builds or improves Ihe,eon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for Such projects with a contracmrts)licensed pursuant to gEWER-SANITAR V-STORM EA.200ft110.00
the Contmmur's Lieense Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&I'.C.fisr this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK 17 RS'COIPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to sell'-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab C.).
Policy NCompanyf
• ❑ Certified Copy is hereb}'(urn6 d. FIRE SPRINK ENERGY T 24
00
F2 Ap Icamlifi d co Iss filed s Rh the city pection division. MISC.- REFER TO ORD. Y C3 No Y ❑ NE]
v�- Cli 'I'PIG T DE EXEMPTION'FROM WORKERS' PERMIT ISSUANCE 10. FLOOD ZONE A.L.UL.
W � COMPENSATION INSURANCE' PLG.CONTR. LIC.NO. PLG.
�
0 1'1Tis section need not be completed if One permit is for one ' TOTAL YE] N E] Y ❑ NE]
C1 O hundred dollurs($100)or less.)
certify thin in the performance of Ilia work for which this ped FEE SUMMARY
LL H Inil is .xued,I shall not employ any person in any Inanncr us as to OTV. MECHANICAL PERMIT FEE
U become subject to the Workey�Compensation Lawsof California.
Q a Date Applicant BUILDING
} m NOTICE 'I'O APPLICANT: If,after nwking this Certlfievlc of Ex- ALTER OR ADD TO MECH. 5.00
Z ennption,you should become subject to the Workers'Compensation APPLIANCE P' 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT.(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLING 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(Seo. MICROFILM
3097,Civ:C.). - HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
LenJer's Address ELECTRIC 33 B-O
I certify that I 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 conslructiol and BOILER-COMP(3H.P.or100,0008.T.U.1 6.00
hereby autlmriae representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP (Over 100.000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expert.ws which PERMIT ISSUANCE 10.00 CONST.TAX
may any way accrue ag' said City in consequence of the
grantilgof th' smolt' MECH.CONT. LIC.NO. MECH.
12 P2 IA TOTAL TOTAL
Si mat rco APPlican ICon )
/�/` INSPECTOR COPY