8775 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT 1 DENTI FI CATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 8775
ADDRESS •
DING-ELECTRICAL-PLUMBING -MECHANICAL
OWrvE ' PLAN CHECK VALIDATION
NAMf
• -sELECTRIC PERMIT FEE
PHONE
NOMERAcrDRs UTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
CONT ALT PPPLIANCES-RESIDENTIAL 4.00
ADDRESS St"
oNE - PANELS 10.00 DATE OF APPLICATION
ARCHEC
�. DR PANELS (OVER 200 AMPI 20.00 PLAN CHECK FEE P.C.NO.
` ENGINEER
/
LIC.NO. SIGNS TRANS. 3.00
ARCHOR ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ESS
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT'$ - MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 /p /
¢ 2 TEMP,POLE 30.00
F O o LICENSED CONTRACTORS DfiCLARATION U
F 0 w 1 hereby ifs ire that I am licensed under provisions of Chrpter'I ISSUANCE DATE
(commencing with,Section 7000)of Division 3 of the Business and N
m a H BLDG. ELECT. PLG. MEC .
F w z Professions Codc,and my license is in full fortff
• c F-1 El z o m - License Class Lia Number
0 m F wC Date Contractor
res'x BUILDING PERMIT
¢ ¢ w a WN e - EER DECLARATION
A 0 a u INFORMATION
X ; ,� y 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u O j Law for the following reason.(Sea 7031.5.Business and Professions VALUATION $/FT.
_ PERMIT ISSUANCE 10.00
Code:Any city or county which regohres a penmt to construct,alter,
¢ u,¢ o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
-G a, requires the applicant for such permit to file a signed statement that TOTALca U. PERMIT TO
w he is licensed pursuant to tire
e provisions of the Contractor's License
Za
Law(Chopter9(commencing with Section 7000)of Division 3.1111, Ld
E i O Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ H $ the bass for the alleged exemption.Any violation of SectioR7031.5 STORIES TYPE CONSTR.
dam _ by any applicant for a permit subjects the applicant toa civil penally ALTER-DRAIN (EA.) 5.00
of not more than five hundred dollars(SSOC).): '
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEV ICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will dothe work,and the structure is not
intended or offered for sal, (Seo 7044, Businass and Professions DRAINS-FLOOR,ROOF,AR EA,GOND. 5.00
Code:The Contractor's License Use does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 S(l ET.FLOOR AREA TOTAL ACREAGE
• himself re through his own offered
for s le.If,provided that such improve- ._
himself a Got through his oroemnoyees, rovi ed thathowevr.such
ebuilding GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
or improvement is sold within one year of completion, - . - . .
the owner- GAS EASYSTEM OVER 4 (EA) 200
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 RES IND CON PB Other
. .
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct tire project(Sec. 7044.Bostic, LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Low does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts for such projects with a contractorls)licensed pursuant to SEWER-SANITARY-STORM EA.2001t/10.00
the Contractor's License Law. TRACT NO, PARCEL NO.
❑ lam exempt under See.-,B.&P.C.for this WATER HEATER W/VENT 6.00
reaSUn
Owner Date WATER SYSTEM 5.00 ACC.DATE ACG FILE No.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby'infirm that I have a certificate nl consent I.self-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or certI Is
CjM� l
TO f rc rnishc '
Z Z ❑ Certili spy s 1, Willi the city inspcclio, t v., n, FIRESPRINK ENERGY T24
O Appliconl MISC.- REFER TO ORD. Y ❑ N❑ v ❑ N❑
~ rnOLN%WPERMIT ISSUANCE 10.00
lr CE 'P KATE F , EMPTI ON FROM WORKERS' FLOOD ZONE A.L.U.C.
W � COPIPENSATION INSURANCIi PLG.CONTE. LIC.NO. PLG.
CL o (This sc n need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
::) Z hundred dollars(51001 or les,.)
U O 1 certify that in the perourrance of the cork for which this per. OTY. MECHANICAL PERMIT FEE FEE SUMMARY
W mit is issued,I shall not employ any person in any ma TOP,so b
eas
U
O U become subject to ilia Workers'Compensation Laws of California.
a Date Applicant BUILDING
} 0 NOTICE '10 APPLICANT: If,after making this Certificutc of I:x- ALTER OR ADD TO MECH. 5.00
F Z
caption,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 10MC.F.M.) 6.00 SEISMIC FEE
I hereby affnd 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
3097,0,C). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Addres HEATI NG UN IT(OV E R 100,000 B.T.U.)9.50 ELECTRIC
s
I certify thin 1 have read this application and crate that tbcubove VENTILATION FAN (SINGLE) 4.00
. Information is correct, I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000B.T.U.) 6.00 PLUMBING
ordinances and slate laws relating to building construction, and
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, indenmify 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 m any way accrue against said City in consequence of the
gr ting of is permit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Si 'fur scant e a t ate o
INSPECTOR COPY