9354 (2) I
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT 8354
ADDRESS
BUILDING ELECTRICAL-
2 , ORS ���'2 _ PLAN CHECK VALIDATION
NAME
4,14"o /.7 CITY. ELECTRIC PERMIT FEE
q PRONE 1 _
's s'
NAME ac RS `•� OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.No. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
ADDRESSDRESSAPPLIANCES-RESIDENTIAL 4.00
PRONE PANELS 10.00 DATE OF APPLICATION
I ORRDRDEcr PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.No.
ENGINEER
uc.NO, SIGNS TRANS. 3.00
ARCR.OR ENG. PERMIT VALIDATION
f ADDRESS SPECIAL CIRCUIT 5.00
ZIP TEMP.METER OR POLE INS. 20.00
ADDRESS MOTORS SEE FEE SCH. j4(
i
SERVICE CHANGE 20.00
w o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
Q,o 0 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
yz w (commencing with Section 7000)of Division 3 of the Business and
¢ BLDG. ELECT. PLG. MECH.
r'D w Professions Code,and my license is in full force and effect ❑ ❑ ❑
z O�., - License Class Lit,Number
-
0 z.-mo Dale Contractor F 'r
¢ ys BUILDING PERMIT
¢ Q;w a
OWNER-BUILDER DECLARATION INFORMATION
F
o•a m 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
a-0 VALUATION $/FT.
F _,o j Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
2 Q(¢ improve,demolish,or repair any structure,prior 10 its issuance,also ELEC.CONTR. LIC.NO. ELEC.
ts
eC u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
, he is licensed pursuant to the provisions of the Contractor's License
Hili Law(Chapter 9(commencing with Section 7000)of Division 3 LittleA'
¢ Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE /
¢�i.o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
•aim by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
'a 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
I 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 SD.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,Provided that such improve-
.cuts 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, the owner- GAS EASYSTEM-OVER 4(EAI 2.00
builder will have the burden of proving that he did not build or int - . .
- BUILDING USE
prove for purpose of sale). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
e ❑ I,as owner of the property,no exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OV ER 5(EA.) 1.00
i contracts for such projects with a contractions)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ l am exempt under See.-,W&P.C.for this WATER HEATER W/VENT 6.00
y reason
Owner le WATER SYSTEM 5.00
PCC.DATE ACC.FILE NO.
WORRIiRS'COMPENSA 1!CLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate ofcousent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
- Policy No. Company
❑ Certified copy is hereby furnished.
FIRE SPRINK ENERGY T}4
z Z ❑ Certilicd mpy Is 01eJ with the city inspection division. MISC.- REFER TO ORD.
O Applicant V ❑ N❑ V ❑ N❑
va PERMIT ISSUANCE 10.00
LU CERTIFICATE COMPENSATION
INSUROhIWORKERS' FLOOD ZONE A.L.U.C.
CL COMPENSATION INSURANCE PLG CONTR. LIC.No. PLG. Y❑ N❑ Y❑ N❑
� Z section need not be completed if the Penni( is for one TOTAL
handled dollars IS 100)or less.) y�,
U O I certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
,LL H mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workeri Compensation Laws of California.
Lid Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} 0 NOTICE TO APPLICANT': If,after making this Certificate of Ex-
Z emplion,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 10=C.F.M.) 4.00
` CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.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,Cie.C.), HEATING UNIT(TO 100,000 B.T.U.) 8.00 OLr_-
( ' Lender's Name HEATING UNIT 100,000 B.T.U.)9.50
r� Lender's Address ELECTRIC
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction. andBOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
(� hereby authorize representatives of this city to enter upon tint BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL (/L
.I above-mentioned properly 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 CONST.TAX
r may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00 rli
granting of this permit MECH.CONT. LIC.NO. MECH.
'°T"` avu TOTAL
r � $Ignal�u�i'pP t ntrd�orbf^�deie- .
INSPECTOR COPY /�