8538 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATIONss PERMIT NUMBER
BD,LDING - APPLICATION & PERMIT
ADDRESS
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL8538
OwNER PLAN CHECK VALIDATION
NAME CITY. ELECTRIC PERMIT FEE'
rPHONE
NAME AD UTLETS-SWITCHES-RECEP 10.00/1.00
_ LIC.NO. LIGHTING FIXTURES 10.00/1.00
ADDRESS PPLIANCES-RESIDENTIAL 4.00
PHONE Z PANELS 10.00 DATE OF APPLICATION
ORCHIE PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P,C.NO.
ENGINEER
LIC,No, SIGNS TRANS. 3.00 1
ARCH.OR ADDRESS ENG SPECIAL CIRCUIT S.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 -
ADDRESS MOTORS SEE FEE SCH.
APPLICA
SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a v u\ 1 hereby affirm that I :un licensed under provisions of Chapter 9 ISSUANCE DATE
v, G i (cmnmencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. M CH.
H m i Professions Code,and my license is in full force and effect
License Class 13 Li,.Nu,nbm
H O Date Contruclor '
Q Y E J
¢ ¢ w a WNIi R-BUILDER DECLARA'IAON� BUILDING PERMIT
a O a - INFORMATION
w 3 a h 1 hereby allirm that I dm exempt from the Contractor's License MISC.- REFER TO ORD
u O j Law for the following reason.(Sec.7031.5,liusinessand Professions VALUATION $/FT.
r - PERMIT ISSUANCE 10.00
Code:Any city or County which requires a permit to construct,alter,
¢ ¢ Q p improve,demolish,or repair any stmct u re,prior to its issuance,also ELEC.CONTR. LIC.NO. FLED.
- 0 E, requires the applicant forsuch permit to file a signed statement that TOTAL
a w m w he is licensed pursuant to the provisions of the Contractors License PERMIT TO
rz
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
z o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r o the basis for tire alleged exemption.Any violation of Section 703 L5 ST RIE -TYPE CONSTR.
a R: _ by any applicant for a permit subjects the applicant tea civil penalty
of not more than five hundred dollars(S5n0f): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEV ICE 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,AR EA,COND. 5.00
Code:The Contractor's License Law dos 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 TOTALACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,tire 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.) 2.00
builder will have the burden of proving Ilia,lie did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 E IND cON PB Other
❑ I,as owner of the property,am exclusively contracting with ❑
El Ellicensed contractors to construct the project(See 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCE L NO.
and Professions Code:lhe Contmclm'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 nmtractons)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. - TRACT NO. PARCEL NO.
❑ I ons exempt under S".-,B.&P.C.for this WATER HEATER W/VENT 6.00
ion
Ow= Dare WATER SYSTEM 5.00 ACC.DATE ACC.FILE N0.'
WORKS RS'COMPFNSA'I'ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sea 3800,EA C.).
Policy No. Company_
0 ❑ Certified copy is herehy, turn e FIRE SPRINK ENERGY T 24
Z Z ❑ Certified co v filed with the c'y 'nspection division. MISC.- REFER TO ORD.
p Applicam Y ❑ NEIY E] NEI
w CER'IIFIC1TIi of li TION 17RONI WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W > COMPENSA'I']ON INSURANC17 PLG.CONTR. LIC.NO. PLG.
d 0 (This wction need net be completed if the permit is for one TOTAL Y❑ N❑ 'Y❑ N❑
:) Z hundred dollars IS 100)or less.)
U 0 1 certify that in the performance of the work for which this Per- CITY MECHANICAL PERMIT FEE FEE SUMMARY'
U_ U mit is issued, I shall not employ any person in any manner so as to
UUJ
become subject to the Workers'Compensation Laws of California.
a Uate Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE TO APPLICANT': If,after making this Certificate of Ex-
Z comfort,you should bcipmc subject to the Workers Compensation APPLIANCE 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 10MC.F.NL) 4.00
CONSl'RUCI'ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work I'or which this permit is issued(Sec. ICROFILM
3097.Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
HEATI NG UN IT 100,000 B.T.U.)9.50 -
Lender's Name ELECTRIC
I certify that I have road this application and state that the above VENTILATION FAN (SINGLE)\ 4.00
ini nndion is correct. I agree to comply with all city� and county - PLUMBING I ordinances and stat, laws trading to building construction, and BOILER-COMPM H.P.or 100,000 B.T.U.) 6.00
hereby molmrize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL /
above Property 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 r CONST.TAX
may in any way accrue against said City in consequence of the
granting of this permit. MECH.CONT. LIC.NO. MECH.
oz ITOTAL
Co TOTAL
SiurL pp want/ Date
1 - INSPECTOR COPY