8357 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENT]FICATION
PERMIT NUMBER
`, BUiLnING APPLICATION & PERMIT ����
- ADDRESS
/ _ � BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER's PLAN CHECK VALIDATION
NAME
QTY. ELECTRIC PERMIT FEE
Lee PHDNE >'r -3
NOME s OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR ADDRESS ACTOR's APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
OR .� PANELS (OVER 200 AMP) 20.00
2A
ENGINEER t za0
LIC.No. SIGNS TRANS. 3.00
ADD ESS ENa SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
2,y rrEMP.METER OR POLE INS. 20.00 ^ i
Ar
Ns MOTORS SEE FEE SCH. ` t
ADDRESS
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 Y
1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
c z w
(commencing with Section 7000)of Division 3 o(lhe Business and BLDG. ELECT. PLG. MECH,
wi Professions Code,and my license is in full force and effect El ❑ ❑ ❑
z O y- License Class Lie,Number
Q z ti Dale Cmnractor
mf BUILDING PERMIT
or a OWNER-BUILDER DECLARATION INFORMATION
X. u. H 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u0Q Law forthe following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
E - � Code:Any city or county which requires a permit to construct.alter,
LE
S 1 0 improve,demolish,or repair anv structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC.
ea
wO LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
es he is licensed pursuant to the provisions of the Contractor's License
Hzi Law(Chapter 9(commencing with Section 700Dof Divnion3 oflhe 99 ��
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE /'C•�7
0 the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
u ; � by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than live hundred dollars(5500).):
❑ L 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 50.FT,FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement Is sold within one year of completion,ththe owner- GAS'-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving at he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
O 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(See. 7044,Business LAWN SPRINKLERS-1 INC 5 V.8. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law docs 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 comractoos)licensed pursuant to SEWER-SAN V-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ l am exempt under Sec ,BAIPC,for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKBRS'COMPEK ,TION DECLARATION 14 WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of-consent to sel&insure' ZONING ENG.SITE N0.
car a certificate of Workers'Compensation Insurance,or a certified
copy thereoff Sec.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished FIRE SPRINK ENERGY T 24
Z O Applicant❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD. vN
❑ ❑ I v ❑ N❑
w CERTIFICAT1i OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W > COhIPENSATION INSURANCE PLG.CONTR. ❑C.NO. PLG. v❑ N❑ v❑ NC] ,
Z (This section need not be completed if the permit is for one TOTAL
hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mil is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
Ed Date Applicant BUILDING /d
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00 S
r2 emption,you should become subject to the Workers'Compensation 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 1Q000C.F.M.) 4.00
CONSTRUCPION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE et6
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 '
the
per o mance of the work for which this permit is issued(Sec. MICROFILM
HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3H.P.or100,0008.T.U.) 6.00
hereby authorize representatives of this city to enter 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 harmless tire City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which' CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
granting Of this permit. MECH.CONT. LIQ NO. MECH.
TOTAL TOTAL 7 f
Signamreuf Applicant/C mract Date
INSPECTOR COPY