C8402 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT '
ADDRESS a
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 4
DANE 'S PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
_• PHONE // J//�• 14/iv/�'r/
NAME
R UTLETS-SWITCHES-RECEP 10.00/1.00J4 _ V
uc.NO. LIGHTING FIXTURES 10.00/1.00
ADDRESS DRS / L PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION 1
w ECT PLAN CHECK FEE P.C.NO.
on PANELS (OVER 200 AMP) 20.00
ENGINEER
uc.No. SIGNS TRANS. 3.00 J
ADDRESS G. -PECIALCIRCUIT 5.00 PERMIT VALIDATION r
ZIP EMP.METER OR POLE INS. 20.00 r L(
ADDRESSTS a MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 ���/ 1•LF�T
0. 2
LICENSED CONTRACTORS DECLARATION TEMP.POLE ,•f 30.00
a U. I hereby affirm that 1 am licensed tinder provisions of Chapter 9 ISSUANCE DATE
v,G w (cont..using with section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH
F w z Professions Code,and my license is in to[[force and effect.
z O m - License Class�++((____gg��Lie Number -
D o o Datc_y��..pt����Contractor Y �� �� I
¢ Yf
¢ ¢ w ¢ OWNER-BUILDER DECLARATION BUILDING PER
w ;n � I hereby affirm nlp
that I am exer fru. the Cuntmetnr's license MISC.- REFER TO ORD
INFORMATION
au u o to Law for the following reason.(Sec.7031.5,dusinessand Professions PERMIT ISSUANCE 10.00 VALUATION g/FT.
Code:Any city or county which requires permit to constant,alter,'
IF Q ¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEG CONTR. LIC.N0. ELEC.
O¢ requires the applicant for such permit to file a signed statement that TOTAL / PERMIT TO
n w m a he is licensed pursuant to the provisions of the Contractor's License
F z i La-(Chapter 9(commencing with Section 7000)of Division 3 oftlse /
¢ [justness and Professions CodeTor that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢ F $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES 'TYPE CONSTR.
by any applicant bar a permit subjects the applicant to a civil penalty gLTER-DRAIN -WATER IEA.[ 5.00
of not more than five hundred dollars(S500).):
❑ 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 (Sea 7144, Business and Professions DRAINS-FLOOR,ROOF,AR EA,CON D. 5.00 f
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 50.FT.FLOOR AREA TOTAL ACREAGE
ov
• himself or through his own employees.provided that such impr .- r
mems are not intended or offered for sale,11,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or arprorcment is sold within one year of completion, the owner-
builder will have the burden of proving that hb
e did not uild or im- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER30.00 RES IND CON PB Dater
.
❑ I,as owner of the property,am exclusively contracting with El 1:1 El": 1:1 1:1w
lic.nsed contractors 1a construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 00 ASSESSORS PARGE:NO.
and Professions Code:The Contractor's License Law do not apply V.B.. .
to an owner of property who builds or improves thereon.and who LAWN SPR IN KLERS-OVER 5 (EA.) 1.00
contracts for such projects with a conrractnrts)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec ,B.&P.C.for this
reawn WATER HEATER W/VENT 6.00
OwnerDate WATER SYSTEM 5.00 ACC.DATE ACG FILE NO.
WORK ERS'COMPI NSATION DECLARA'T'ION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate ofcnmmlt to self-ir.sur..
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
�C copy thereof(Sec.3800,Lab.Gl.
r Policy Nu. Company f, tA.4a(�
❑ Certified mpY is hereby with
the /fi�ee 'Y ��yy('
z Z ❑ Certified c'n iz filed.with thP-ni(�R1ZrE �bJ�d FIRE SPRINK 'ENERGY T 2
up, p li n t11viNon. Y E] N❑ V ❑ N[:]p Applicant MISC.- REFER TO ORD.
N (ER'I'I PICA'I'I':OF EXI MPT l ON PROM )RKIiRS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W 1 COMPENSATION INSURANC i PLG.CONTR. LIC.NO. PLG.
CL IT'his section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
2 hmWrcd dollars IS 100)or lewd
U 0 I cattily that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any person in any manner w as to
become subject to the Workers'Compensation Laws of California.
U a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} rA NOTICE*TO APPLICANT: If,after making this Certificate of Ex-
2 emption,you should become subject to tlu•Worker's Compensation APPLIANCE 5.00 4L 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 100MC.F.M.) 4.00
CON'STRUCT'ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE - ' D
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(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 6.00'
Lender's Add. HEATING UNIT(OVER 100,000 B.T.U.)9.50 /�
Lender's Addr.ss ELECTRIC
I certify thin l have read this application andslate that the above VENTILATION FAN (SINGLE) 4.00
inl'mmution is correct. I agree to comply with 111 city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representative,natives of this city to enter upon theAtareBOILER-COMP (Over 100.000 STU)SEE FEESCH. MECHANICAL
hereby
millmo,timned propertyfative,or of this
purposes.
(we) agree to sme,�indemnify and keep hornless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE ORD ' CONST.TAX
e
may in any way accruagainst said City in consequence of the10.00
grantingofthis permit. MECH.CONT. LIC.NO. MECH,
TOTAL TOTAL
INSPECTOR COPY