C8138 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING
BUILDINGAPPLICATION & PERMIT
/ F 81, 38
ADDRESS \(\!^/y
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'A PLAN CHECK VALIDATION
NAME TV. ELECTRIC PERMIT FEE
CONTL (09
CONTRACTOR
NAMEOUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO, LIGHTING FIXTURES 10.00/1.00
ADDRESS RRAcroR's APPLIANCES-RESIDENTIAL 4.00
ADD
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
�I ENGINEER
c G SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION
X
ADDRESS 6 SPECIAL CIRCUIT 5.00
zIv EMP. METER OR POLE INS. . 20.00
A ANr'sI 1 •04041_ MOTORS SEE FEE BCH. J
ADDRESS UN
SERVICE CHANGE 20.00 /T�/yi/��
o o LICENSED CONTRACTORS DECLARATION - TEMP.POLE 30.00 l/ U
a v u I hereby afflnn that I am licensed under provisions of Chapter 9 ISSUANCE DATE
H < H (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F w z P,.IcssionS Code,and my license is in full force and effect.
z o m - License Class Lia Number 20
z w Dale Contractor
ay f BUILDING PERMIT
¢o i OWNER-BUILDER DECLARATION INFORMATION
F
I- I hereby affirin that I am exempt from the Contmctor'.s License MISC.- REFER TO ORD
Huo J Law for tire following reason. 703).5,Nusinc,Smd Prol.,mos pERMIT ISSUANCE 10.00 VALUATION S/FT.
wj Code:Any city or county which requiresa permit to construct.alter, �CI 4
Q so Q improve.demolish.Or repair arty structure,prior to Its Issuance,also ELEC.CONTR. LIC.NO, ELEC.
tod
Sic
requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w m he is licensed pursuant to the provisions of the Contractor's License J
HiQLaw(Chapter 9(commencing with Section 7000)of Division 3 oflhe //(/TErQ vOQ \C/L/U OE
E o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
I- m lite basis for the alleged exemption.Any violation of Section 703 t.5 STORIES TYPE CONSTR.
n ; - by any applicant for a permit subjects the applicant too civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
0 I,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 slmcture is not
intended or ol'fcrab for Sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:'rhe Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SD.FT.FLOOR AREA TOTAL ACREAGE
himselforcornerhrough ed ownemployees,for sale.
It,ed that however,
the
improve- GAS-EA.SYSTEM-I 6.00
mems are not intended or offend for sale.Il',however,the building
m improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im- REB IND CON PB Other
to •1.as A. INDUSTRIAL of sale.). INDUSTRIAL WASTE INTER. 30.00
I,as owner of the property,am exclusively contracting with
lice sed.contractors to construct the project ISec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Profeision5 Code: rhe Contractor's License Law does not apply
to an owner U property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
convects forsuch projects with a contractons)licensed pursumrl to
the Cunt m.I.,s License Law. SEWER-SANITARY-STORM EA.2001t/10.00 TRACT NO. PARCEL NO.
❑ lam exempt lender Sec. .B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Ownert 0.5;9// Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
R;gAc :N. 1-1 r.01 A WATER TREATING EQUIP. 5.00
I hereby'affirm that I have fCAftse t iA1T
or a certificate of Workers'Compensation Insurance,or cel ed ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby tarnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copyis filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant V N V❑ N[:]
Cr y CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOOZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLGEL 0 .
Z (I'IRS section need not he completed if the permit is lift one TOTAL Y N� V N� -
hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any manner so as to
O w become subject to the Workeri Compensation Laws of California.
D. Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOI ICE TO APPLICANT: 11,after making this Certil'ici le of Ex-
F Z coalition,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK /�[ 1
provisions of rite Labor Code, you must forthwith comply with FEE G 44
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10A0DGF.M) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p00C.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(Sec. MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lenders Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
i rdina cis n coarct. I agree to comply with all city role 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 representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
a mec-mentioned 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 CONST.TAX
may in any way accrue against said City in consequence of the
ntin f this penni6 >- MECH.CONT, LIC.NO. MECH.
115 roTAL TOTAL
leff.046W Mip1iA?rrTCrnt?a' Dat
INSPECTOR COPY