8315 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
UILDIN
ADONEG APPLICATION & PERMIT _ g315
S /� ` BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER' ' l PLAN CHECK VALIDATION
NAME' QTY. ELECTRIC PERMIT FEE
• vHON _ G l
AM1ERACTGRs
NUTLETS-SWITCHES-RECEP 10.00/1.00
Ouc.NO, ,�f LIGHTING FIXTURES 10.00/1.00
ADDRESS R's PPLIANCES-RESIDENTIAL 4.00
CONTRA
PHOrvE _ PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENG - SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
zlvrrEMP. METER OR POLE INS. 20.00
ADDR SSTs MOTORS SEE FEE SCH. _l
SERVICE CHANGE 20.00 /
00 LICENSED CONTRACTORS DECLARATION TEMP. POLE 30.00 //d f`
C ¢ u u I hereby allinn that I um licensed under provisions of Chapter 9 ISSUANCE DATE
' y < N (conmrencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. I MECH.
r m z 1`oofessions CIc,urul•at licunI is in full fort w I
Z o w - License Cla Eon Number
o a r D Datc��./ Cont meter
BUILDING PERMIT
M < OWNER-BUILDER DECLARATION INFORMATION
w3 s. w I hereby u01nn that I am exempt from the Contractor's License MISC.- REFER TO ORD
.. oj Law for the following reason.(See.703L5,Business and ProfessionsF. PERMIT ISSUANCE 10-00 VALUATION S/FT.
2 Code:Any city orcounty which requires a permit toconslrucL alter,
�� ELEG.CONTR. LIC.NO.
o improve,demolish,or repair any structure.prior to its issuance.also ELEC.
-O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
n wm he is licensed pursuant to the provisions of the Contractor's License ,
i
Low(Chapter 9(commencing with Section 7000)of Division 3ofibe n
io Business and Professions Code)or that he is exempt therefrom and GTI. PLUMBING PERMIT FEE Lt3 V"
H m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
La by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER (EA.) $.00
of not more than five hundred dollars(S500)J: '
O 1,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 do the work,and the stracmre 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 town owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees.provided that such improve-
mentsarenotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 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
RES IND CON PB Other
.prove for purpose of f tire
INDUSTRIAL WASTE INTER. 30.00
❑ d as owner of the property,ant roicrtivSe contracting with
El El El ED 11
licensed cmnrumom neCon¢t the priced(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
,old Professions Code:fit he Contuilds o License .Law docs not apply
to tr owner of properly who builds t r iumns)licensed
thereon.and who LAWN-SPRINKLERS-OVER 5 (EA.) 1.00
contracts Iia such cense L with a eantructogs)licensed pursuant to
the Convactori License Law, SEWER-SANITARY-STORM EA.200ft/10.00 T ACT NO, PARCEL NO.
O I am exempt under Sec. .HAP_C forthis WATER HEATER W/VENT 6.00
reason5.Date WATER SYSTEM 5.00 q ,DATE ALL.FRE N0.
WORK IiRS'COhi PIiNSAT10N DECLARATION WATER TREATING EQUIP. 5.00
1 hereby afrnn that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certific to of Workers'Cmnpensation Insurance,or a certi 'ed
cop)1he tT�' g G.
roU -1✓A,�J-8,s lam"y�
O a ecrOtmd copy is hereby U nisltcd. FIRE SPRINK ENERGY T-24
z Z ❑ Certified copy is ti E with the city inspection division. �
O Appl;)p, tt� / i- MISC.- REFER TO ORD. v ❑ N E-]
❑V N❑
X i2 / CERTIFICATE 01:E\ENIPTION FROM tyOR KERS' PERMIT ISSUANCE 10.00 FLOODZONE' A.L.U.C.
CL LLJ > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. �" V� NE] V� NC]Z CI'his section need not be completed if the permit is for one TOTAL
te hundred dollars IS 100)or I.A.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
EL U mil is issued, I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
Date Applicant BUILDING
d to ALTER OR ADD TO MECH. 5.00
} rn NOTICE TO APPLICANT': If,after making this Certificate of Ex-
Z cntption,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 decried revoked. AIR HANDLING UNIT(TO 10,000GF.M.) 4=
CONS'TRUC'HON LENDING AGENCY AIR HANDLING UNIT(OVER 1Q000QF.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency tot EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Ser. MICROFILM
3097,Civ.C.). H EATING UN IT ITO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that l have read this application and state• that the above VENTILATION FAN (SINGLE) 4.00 (/v information is correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city' Ir enter upon the
above mentioned property for inspection purpoBOILER-COMP lower 100,000 BTU)SEE FEE SCH. MECHANICAL
ses.
(We) agree to Save, indemnify 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 in any way accrue against mid City in consequence of the
grant) Of th' ermit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL /D
ur o Applicant Contractor Date
INSPECTOR COPY