8320 (2) 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 ��
aoo ss
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OwNE S. PLAN CHECK VALIDATION
NAME �) QTY. ELECTRIC PERMIT FEE
.I/l-( PHONE-'2 -/
CONTRACTORS-
NAME
N RACTORSNAME UTLETS-SWITCHES-RECEP 10.00/1.00
UC.NO S( 7, LIGHTING FIXTURES 10.00/1.00
C-ONTRACTOWS
ADDRE _ PPLIANCES-RESIDENTIAL 4.00
SS
L �� PHONEIJ •afi PANELS10.00 DATE OF APPLICATION
OgcmT Cr PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER
Lie NO. SIGNS TRANS. 3.00
o DHEss BRa SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP,METER OR POLE INS. 20.00 ���
AMOTORS SEE FEE SCH.
ADDRESS
oREss
SERVICE CHANGE 20.00 (( i
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a v I hereby uf6rnt that 1 am licensed coder provisions of Chapter 9 ISSUANCE DATE
yam (commencing with Section 7000)of Division 3 of the Business and, BLOC. ELECT. PLG. MECH.
H w z Professions Cod and my license is in full torr I a dP(f ❑ ❑ ❑ ❑
z o n - License Class L- Lic.Numbc 1==�L /�'�-'
H r Date Contractor
a x U BUILDING PERMIT
06U OWNER-BUILDER DECLARATION INFORMATION
F
3 LL H 1 hereby affirm that I am exempt from the Contractors License MISC.- REFER TO ORD -
,Fuoa Law for the following reason.(Sec.7031.5.Business and Professions pERM1T ISSUANCE 10.00 VALUATION $/FT. .
Code:Any City or county which requires a permit to construct,alter,
QwELEC.CONTE. LIC.NO.
ar a requires,irelappic Or repair any Strnetofi quare to its issuance,also ELEC.
i - O a requires the applicant I'or such perurit to file a xContractor's
ont aWtms Li that TOTAL
w m u Law(Chapter
pter pursuant to the with provisions of the Conlmetoi a License PERMIT TO
H Z 'a Business
fCha and
Professions
de)or than ie is exempt
therefrom
and
4 D Business and Professions Code)or that he is exempt therefrom Ind QTY. PLUMBING PERMIT FEE
va I- a the basis for the alleged exemption.Any violation of Section enol STORIES TYPE CONSTR.
u 3 m by any applicant for I permit atbjeas the applicant too civil penalty
afoot more than five hundred dollars($500f.): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ I,as Owner of the property,or my employees with wages is BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
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,AR EA,COND. 5.00
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 SQ FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
memsarenotintendedorofferedforsale.lf,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 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 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-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
U I em exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSAT ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to sdf omrC, ZONING ENG.SITE No-
or a certificate of Workers'Compensation Insurance,or a cel Tied
copy t�hx leo I 380 ,l,ub.0)'
pureYL`•' �� OY
an
Q ❑ ertifie hTi tams. edf FIRE SHRINK ENERGY T-24
Z Z ertified copy is file) wi0i theity inspection division.
0 AI' °IDS. MISC.- REFER TO ORD. YEl N❑ vQ. NE,
2 = CERTACA'TIi OP EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 LL �(/ FLOOD ZONE A.L.0 F.
LU > COMPENSA'T ONINSURANCE PLG.CONTE. uC.NO. PLG.
Z
This section need not be Completed if the permit is for one TOTAL /�� V❑ N� V N�
hundred dollars IS 100)or Icss.l
L) 0 I Certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued. 1 shall not mnploy any person in any manner so as to
0 become subject to the Workers'Compensation Laws of California.
a Darn Applicant BUILDING
>_ to NOTICE TO APPLICANT': It;after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
emption,you should become subject to the Workers'Compensafton APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most I..f with comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1Q000CF.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000C.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.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
e HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lenders Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 ��/
information is correct. 1 agree to comply with all City and county PLUMBING h"U IV
-
hereby
and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorise representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino Igftlost liabilities,judgments, costs and expenses which pERM1T ISSUANCE 10.00 CONST.TAX
may in an�IAW
aaccrue against said City in consequence ofthegranting ofp� MECH.CONT. LIC.N0. MECH.�/� TOTALSinatui plicae/Contractor b; /~
/ - INSPECTOR COPY