C8421 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LD ING PROJECT I DENTIF I CATION PERMIT NUMBER
BN,LDING APPLICATION & PERMIT
•-�`• aooREss
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OwN R'S - A421
PLA HECKVALIDATION
• NAME �, • QTY. ELECTRIC PERMIT FEE _ �X/^/ y./ _
PHONE !�[S ,\ "/I
�z -�' .
rvAmpRacTpR OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO. LIGHTING FIXTURES 9D-00/1.00
ADDRESS
ECTons PPLIANCES-RESIDENTIAL 4.00
CONTRA
PHONE PANELS 10.00 PATE OF APPLICATION
AR0.CHrtECT /I �[,,�/__1v(/I y1./�O�•-y-y. Y PANELS (OVER 200 AMP) 20'0@ S� PLAN CHECK FEE P.C.NO.
r ENGINE V, ' -� I'� ' '� �•
SIGNS TRANS. 3.00
ADov'ESS SPECIALCIRCUIT 5.00 PERMIT VALIDATION
EMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
�OOREss �Iv
QS SERVICE CHANGE 20.00
, O'o' LICENSED CONTRACTORS IIECLARA'['ION TEMP.POLE 30.00
< re u I hereby.from (hat I am licensed under provisions of Chapter 9 ISGU E ATE
sit a y (commencing with Scetion]000)of Division 3 of the Business and BLD ELEC PL MECH
F w z Professions Code,and my license is in full force and effect.
z'O m - License Class Lia Number
o z as - Date Contractor
m f BUIL ING E MIT
6o u OWNER-BUILDER UILDIiR DIiCLA RATION INFORMATION
X 3 LL y I hereby affirm ilial I am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION
to 04 Law for the following Reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 7000 o-0
Code:Any city orcounly which requiresapermil beanstruet,uller,
K ¢¢Q improve,demolish,or repair tiny structure,prior to illi issuance,also ELEC.CONTR, LIC.NO. ELEC. (�00
O¢ requims the applicant for such permit to file a signed st atemunt that TOTAL PERMIT TO
itm u_ he is licensed pursuant to the provisions of the Contractor's License
r z i Law(Chapter 9(commencintwill,Section 7000)of Division 3ofthe
a Business and Professions Code)or Ilial he is exempt therefrom and QTY. PLUMBING PERMIT FEE -
r O the basis for the alleged exemption,An s
oe b p the
eapplica of Section malty STORIES ^E N$TA:
by any applicant lira porn does theapplic;uv mucivilpcn°Ity ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five the prop dotes(my em): ]
O Las owner at the properly,or my employees with wages as / BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole r offered
ion,will(S the work,and este structure is not
intended or offered for sale (Sec. 7014, Business and.Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply loan owner of
property who bolds Or improves IhCIPOn,and who does SOC1 WUr .j FIXTURES-PER TRAP 5.00 SO,FL FLOOR AREA TOTAL ACREAGE
himself or tivotigh his own employees,provided that such improve
mems are not intended or offered for sale.IC however,the building GAS-EA.SYSTEM-l ,
or improvement is sold within one year of completion, the owner-
Up
wner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00
L, buil er will have the burden of proving that he did not build or int- BUILDING USE r
• 'for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON pe Omer
c I,as owner of the property,:un exclusively contracting with ❑ ❑ ❑ ❑ ❑
_ li cried unvractors to construct the project (Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 �. ASSESSORS PARCEL NO.
- rd Professions Code:I'he Contractor's License Law docs not apply
o an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractorls)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.2001t/10.00 TRACT NO. PARCEL NO.
�,❑_I,at,,exempt under Sea_ .B.&1'.C.for lits WATER HEATER W/VENT 6.00
•rCJSnn
Owner Late WATER SYSTEM 5.00
3 ACC.DATE ACF FILE N0.;55 '
WORK I?RS'COM1 NSATION DECLARATION WATER TREATING EQUIP. 5.00
/
I hereby affirm that I have a certificate of consent to self-insure. ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Scc.3800.Lah.C.). 's
Policy Nn. COmpany
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY R]4
Z Z ❑ Certified copy is filed with the city inspection division. ISC. REFER TO ORD.- .
O Applicant MY❑ N❑ Y ❑ N❑
-N'/ Cl:RTI PICA IT OI'1:XBMPI'ION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.UC.
LU > COM1IPF,NSATION INSURANCE: PLG.CONTR. LIC.NO. PRfiiii' `� v❑ N❑ v ❑ NEI.
( This section need not be completed if the permit is for one TOTAL / w
hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this perQTY. MECHANICAL PERMIT - FEE FEE SUMMARY
LL E- it is issued,1 shall not employ any person in any manner so as to
r Ow beconto subject to the Workers'Compensation Laws of Califonua. BUILDING
C. Dale Applicant ALTER OR ADD TO MECH. 5.00 _
} N NOTICE: TO APPLICANT: If,after making this Certificate of fix-
• Clinion,you should become subject to the Workers'Compereation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwilh comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M,) 4.00
CONST'RUC'T'ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE /tl
E I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
re Civ mance of tire MICROFILM
e work for which this permit is issued(See. HEATING UNIT(TO 100,000 B.T.U.) B.00
a
1. Lender,Name HEATING UNIT (OVER 100,000 B.T.U.)9.5 - -
Lender,Address ELECTRIC ,�-
ry
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 (p �_
information is state
l ctelI agree IO comply with all city and county PLUMBING •`
ordinances and stale laws relating to building construction, and BOILER-COMP I3 H.P.or 100,0008.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
abovoratmooned property for inspection purposes. BOI LER-COMP lover 100,000 RTU)SEE FEE SCH. MECHANICAL
(We) agree to save. Indemnify and keep Imrndess the City of MISC.- REFER TO ORD,
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX - O
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
gran ling0frispenniL MECH.CONT, LIC.NO. MECH. /�) Vu
TGTAL TOTAL
n ore a A p icon on m or t
INSPECTOR COPY
I I