8470r
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT 1 DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
7 O vHII Dd C 4 BUILDING-ELECTRICAL-PLUMBING -MECHANICAL 8470
0NER'S PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT 1 FEE
• 1 PHONE Q S
NFMERAcroRs OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC..Oig MSeAlLIGHTING FIXTURES 10.00/1.00
ADDREScrOas APPLIANCES 4.00
I L AooREss _ 1
12 7PHONE _ PANELS 10.00 DAT EOE APPLICATION•.
C EC PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMPI 20.00
ENGINEER
LIC.NO. SIGNS TRANS. 3:00
ARCH.OR ENG. PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5:00
ZIP rIFEMP.METER OR POLE INS. 20.00 /ADDRESS
LICA
APPLICANT$ MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 I I
woo LICENSED CONIRAC'I'ORS DECLARATION TEMP.POLE 30.00so
a u u I hereby affirm that I am licensed under provisions of Chapter 9 v ISSUANCE DATE
(commencing with Section 7000)'of Division 3 of the Business and
D" Professions Code,and m license is in full force and effect, BLDG. ELECT. PLG. MECH.
so
z
oi p License Clas Lie.Number -gAeEl
r m r J�` Date ' Contractor
a m s x�CNd UILDING PERMIT
¢ a, it 4 OWNER-BUILDER DECLARATION INFORMATION
F
; a m I hereby affirm that 1•am exempt from the Contractor's License MISC.- REFER TO ORD
r u o J Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00
VALUATION S/FT.
m Code:Any city or county which requires a permit to construct,alter,
p _
¢ ar Q 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. L DOO
a wDLL 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',License
H z a Law Chapter 9(cmmnencing with Section 7000)of Division 3.1 the
E iD Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE �V17 W/b
¢ H m the basis kir the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a3 _ by any applicant for a permit subjects the applicant to a odpenalty ALTER-DRAIN -WATER IEA.) 5.00 '
of not more than five hundred dollars(5500).):
❑ 1,as owner of the property,or my employees with wages as BACK F LOW 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 Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractors License Law does not apply to an owner of
property who builds or Improves thereon,and who docs Such work F IXTUR ES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTALACREAGE
himsll' ,,through his own employees,provided that such imprwa
mems are not intended or offered liar sale.If;however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner
GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
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
❑ I,as owner of the property,am exclusively contracting with . .
❑ ❑ ❑ ❑
licansed contractors to construct the project(Sea 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSOR ARCEL NO.
t and Professions Code:'I'he 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 cmntractous)licensed pursuant to SEWER-SANITARY-STORM EA.2001t/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
O I at,,exempt under Sc,.-,B.&P.C.]or this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE N0.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate of consent to sell-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof tScc.3900,Lab.C.). -
';1 Policy No company + _
O ❑ Certlfi do is hereby f nlsl • FIRESPRINK ENERGYTQ4
Z Z ❑ Certified & is filcZdhe cit, inspection division. MISC.- REFER TO ORD.
O Applicant - Y❑ NE] Y ❑ N❑
CCN C1. 11'ICA'I'Ii F EXEMI"ION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE, A.LU,C.
LU > COMPENSATION INSURANCIi
PLG.CONTE. UC.NO. PLG.
d O (Phis section need not be completed if the permit is for one TOTAL Y❑ N❑ Y E) NE]
hundred dollars(SI00)mules'.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,1 shall not employ any person in any manner so as to
beconra subject to the Workers'Compensation Laws of California.
a Date Applicant BUILDING
} to NOTICE'10 APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
f- Z emption,you should become subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you muv forthwith comply with FEE
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONS'I'RUCTION 1.17NDING AGENCY AIR HANDLING UNIT(OVER 10,MOQF.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 r
the performance of(he work for which (his permit is issued(Sec. MICROFILM '
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
NHEATING UNIT(OVER 100,000 B.T.U.)Lender's NAdd,came ELECTRIC
Icertify that l have read this application and state that tbeabove VENTILATION FAN (SINGLE) 4.00
inl'onnmion is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.Dr 100,000 B.T.U.) 6.00
hereby authorize representatives of this city es enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for insP of ion purposes.
(We) agree to save, indemnify and keep hurnless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs anJ expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may as ny way accrue agai t said City in con s"moce of the
graph f this perm . MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
A -anc(' nr or flDaly
INSPECTOR COPY