C8340APPLICANT TO FILL IN INFORMATION WITHIN RED LINES = USE BALL POINT PEN ONLY
BU LDING PROJECT 1 DENTI FICATI ON
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICA
PERMIT NUMBER
BUILDING
ADDRESS
/.O� !'v'�'J
(Y
OWNERS
NAME
OTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
/T oNE
,
RACT FT
NAME
UTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
I /j
i '„ LIC. NDt
PV OT i ' / J
A OORESS
APPLIANCES -RESIDENTIAL 4.00
PANELS 10.00
j
�I PRONE q
DATE OF APPLICATION
q ` 1PLAN
OR `
ENGINEER
LIC. No.
PANELS (OVER 200 AMP) 20.00
CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH, SS ENG.
CIRCUIT 5.00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00
ZIP
I S
ADDRESSTs
MOTORS. SEE FEE SCH.
"�/A
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
TEMP. POLE 30.00
I hereby affirm that I am licensed under provisions of Chapter 9
commrncing with Section 70001 O( Division 3 Of the Business and
professions Code, and my license is ie full force and effect
License Classi - 6 y Lic. Number qfr "sem o
ISSUANCE DATE
BL
ELECT.
❑
PLG.
❑
MECH.
Date c- y.�T Contractor,,AkF,_,m
BUILDING PERMIT
INFORMATION
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5. Businessand professions
Code: Any city or county which requires a permit to construct, alteq
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such pennit to file a signet) statement that
he is licensed pursue Tit to the Provisions ofthe Contractor's License
MISC.- REFER TO ORD
VALUATION
V
$/FT.
PERMIT ISSUANCE 10.00
ELEC. CONTR. LIC. NO.
ELEC.
TOTAL
PERMIT TO
CITY. PLUMBING PERMIT FEE
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
1 STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation o(Seetion 7031.5
by any applicant for a permit subjects the applicant o a civil penalty
of not more than five hundred dollars(5500).):
O
U ��
ALTER-DRAIN&VENT-WATER IEA.15.00
❑ ,, as Owner of the property, or my employees with wages as
their sole -compensation, will d0 the work, and the structure is not
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAIN$ -FLOOR, ROOF, AREA, COND. 5.00
intended or offered for sale (Sce. 7044. Business and Professions
Code: The Contractor's License Law does not apply to an owner of
property who builds Or improves thereon, and who does such work
himself Or though his own employees, provided that such improve-
ents e not intended or offered for sale If, LOwever, the building
mar
FIXTURES - PER TRAP 5.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
'
GAS - EA. SYSTEM - 1 INC. 4fOUTLETS 6.00
or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or am-
provefor purpow of sale.).
❑ 1, as -owner of the property, am exclusively contracting with
GAS - EA. SYSTEM. -OVER 4 (EA.) 2.00 -
BUILDING USE
RES IND CON PB Other
❑ ❑ a ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct the project (Sea 7044, Business
and Professions Code: The Contractor's License Low does Tint apply
to an Owner (i1' property who builds or improves thereon, and who
LAWN SPRINKLERS- 1 INC 5 V.B. ' 6.00
ASSESSOR RC EL NO.
LAWN SPR INKLERS - OVER 5 (EA.) 1.00
contracts for such projects with a contractous) licensed pursuant t0
the Contractors License Law.
SEWER-SANITAR V -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO. '
❑ lam exempt unde(Sec. ,B..GItC. for this
r�
WATER HEATER W/VENT 6.00
reason
Owner Date
WATER SYSTEM 5.00
ACCC.'oATE
ACC. FILE NO.
WORKER$'COMPENSA'I' ION DECLARATION
WATER TREATING EQUIP. 5.00
1 heathy affirm that I a certificate Ir consent o a (-insure,
or a certificate of Workers's' Compensation Insurance, or a curti(itt1
' iY�
ZONING
ENO. SITE NO.
copy thercof(Scc. 3800, Lab CA
Policy No. S�...�Company �n..� /�-
❑ Cellihed tOpy ishereby ""Pany mmshed. '
Q�CerliGed copy is filed with the city inspection division
Applicant _
FIRESPRINK
V ❑ El
ENERGY T-24
V ❑ N❑
MISC. - REFER TO ORD.
(,F;R'I'IPIG\'I'fi OF EXEh1 p"PION FROM WORKERS'
PERMIT ISSUANCE 10.00
.!I
FLOOD ZONE
A.L.0 C:
PLG. CONTR. „ LIC. NO.'
PLG.
?OTAL
COMPENSATION INSURANCE
('this Section need net be completed if life Permit is for One
V N ❑
iY ❑ No
hundred dollars(S 100) or less)
' I certify that in the performance of the work�or which this per-
mitis issued, 1 shall not employ any person in any manner so as to
OTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
-
become subject to the Workers' Compensation Laws of California.
Date Applicant
NOTICE '1'0 APPLICANT: If, after making this Certificate of Ex-
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00
PLAN CHECK
FEE /
emptum, you should become Subject to the Workers'Compenmtfon
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT (TO 100WC.F.M.) 4.00
AIR HANDLING UNIT (OVER 10=C.EM.) 6.00
SEISMIC FEEUnt
CONSTRUCTION LENDING AGENCY
I hereby uffrmthat 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.
3097, Cie.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address
H EATING UNIT (OV ER 100,000 B.T.U.) 9.50
ELECTRIC
I certify that l have read this application and spree that Ole above
VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city a.A county
ordinances and slate laws relating to buildingconshuclion, and
PLUMBING
BOILER - COMP (3 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,000BTU)SEEPEESCH.
MECHANICAL
-hereby authorize representatives of this cite ro enter upon the
above-memomed 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
may in any way accrue against said City in consequence OI' life
CONST. TAX
PERMIT ISSUANCE 10 .00
granting of this permit.
MECH. CONT. LIC. NO.
MECH.
TOTAL
TOTAL
�l
t pp ¢ r c or' Date,
I
INSPECTOR COPY~