C8327 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDINGn APPLICATION & PERMIT (� �s�J
DDRESS
9Y/�[ BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 753 ,/ t
OWNER'S - PLAN CHECK VALIDATION
+/ NAME
•,.T /I DTV. ELECTRIC PERMIT FEE -7 (J
/•l/ O r PHONE ��� /
CONTRACTOR'S
NAME nOUTLETS-SWITCHES-RECEP W-</1.00
LIC.No. LIGHTING FIXTURES x/1.00
ADDRESS ro 's APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C.NO.
ENGINEER
' uc.No. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIALCIRCUIT $,QQ PERMIT VALIDATION
ADDRZIP fTEMP.METER OR POLE INS. 20.00 `.
Ars
ADDDRESSDRESS MOTORS SEE FEE SCH.
/SERVICE CHANGE 20.00 ' Q
0 0 o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 `
Z
cHi I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w G H (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H w z Professions Code,and my license is in full force and effect ❑
zm o License Class Lie.Number
j Date.Contractor
Q y sI BUILDING P RMIT
re BE w er OWNER-BUILDER DECLARATION
A 0 a U INFORMATION
wg LL N I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
LL D j Law for the following reason.(Sec.7031.5,Business and Professions VALUATION SOFT.
- PERMIT ISSUANCE 1
Code: e.Ocity or county which requires a permit to construct,alter,
2 Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. FLED.
Ll- requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w mhe is licensed pursuant to the Provisions of the Contractor's License _F
HZQ Law(Cbapter 9(commencing with Section 7000)of Division 3 o fthe /T.r-}�j
4 D Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE YI✓ ✓
H o lite basis for the allcgcd exemption.Any vmhdion of Section 7031.5 STORIES TYPE CONSTR.
u3m by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER (EA.) 5.00
Off not more than five hundred Jollars($500)J.
C3 as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCG GROUP RES.UNITS
their sole compensation,will do the work,and the structure Is not
intended or offered for sale (Sec. 7044, Business and Pro(cssions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractors License Law docs not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5 i So.FT.FLOOR AREA TOTALACREAGE
• himself or through his own employees,provided that Such improve-
menu arc not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year o1completion,thener- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not builow
d or ire- \ BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 IND CON PB Omar
I 1,as ownm m
er of the property,aexclusively cometiag with 1:11:1 11 11IicLnsed contractor, to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:Il ie 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
tmtlracts for such projects with a contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ l am exempt underSec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
X Owner Date - WATER SYSTEM 5.00
i ACO.GATE ACG FILE NO,
WORKE:RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have u certificme of Consent to sell-insure,
or a certificate of Workers'Compensation Insurance,or a terrified ZONING ENG.SITE NO.
copy thereof(See.3800,Lab.C.).,
Policy No. Company
O ❑ Certified copy i5 hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is fled with the city inspection division.
FO Applfc,nt MISC.- _ REFER TO ORD' Y � IN Y ❑ NE]
CC w CERTIFICATE OP EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10 FLOOD ZONE A.L.0 c.
W > C0h114:NSAT10N INSURANCE PLG.CONTR. LIC.NO. PLG.
d 0 (This section need not be completed if the permit is for one TOTAL 01
Z hundred deltare(S 1001or less.)
U O 1 certify that in the performance of lite work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
IL j- mit is issued,I shall not employ any person in any manner so as to
U U become subject to the Workers'Compensation Laws of California. �}'y
2 Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING I
} W NOTICE TO APPLICANT: If,after making this Certificate.P rix-
F Z emption,you should become subject to the W'orkeri Compensation APPLIANCE 5.00 PLAN CHECK
oroh visions of the Labor Code, you must forthwith comply with
suFEE /
U cprovisions or this permit shall be deemed revoked. AIR HANDLING UNIT ITO 10,00DC.F.M.) 4.00
CONSTRUCTION LENDING ACI7NCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a Construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of thi work for which this permit is issued(Sec MICROFILM
3097,Ci,C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name. HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender:Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
•
ordinances nis andcstatet lawsrelree atingrelatincomply with all City and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
6 to building con teriCt ion, and
hereby authorise representatives ins of this city to etiterguPon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
41wve-mentioned property for inspection purposes. 'pl
(We) agree to taut, indemnify and keep harmless the.City of MISC.- REFER TO ORD.
t 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
'Ming Of this permit MECH.CONT. LIQ NO. MECH.
°T�` TOTAL I�
r ,
Signaq.
ture of ApP ic' t Contactor Uate
INSPECTOR COPY
z
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