8377 APPLICANT TO FILL IN INFORMATION WITHIN'RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
AOOREss
IJ �� BUILDING - ELECTRICAL-PLUMBING-MECHANICAL - 8377
o OOOTTT
OWNER'S PLAN CHECK VALIDATION
/
_NAME ^ QTY. ELECTRIC PERMIT FEE �',y,//
PHONE I
CONTifs
NA.L crORs UTLETS-SWITCHES-RECEP 10.00/1.00 VV
1 NAME
i,IC.NO. Q If& ILIGHTING FIXTURES 10.00/1.00
CONTRACTOR
ADDRESS APPLIANCES-RESIDENTIAL 4,00
T CONTR
rr PHONE - / PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHEE77 P.C.NO,
OR
ENGINEER
uc.No. SIGNS TRANS. 3.00
ADDRESS E.G. SPECIALCIRCUIT 5.00 PERMIT vnuonnoN
ZIP EMP.METER OR POLE INS. 20.00 '
APPLICANTS MOTORS SEE FEE SCH.
AODR Ess r
SERVICE CHANGE 20.00 J
i
0 0 o IJCIiNSED CONTRACTORS DECLARATION TEMP.POLE 30.00 T /`/f}
< u u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
,H4 Q N (commencing with Section 7000)of Division 3.1 the Business and BLDG. ELECT. PLG. I MECH.
H m z Professseions Code,and my license is in full force and effect ❑ ❑ ❑ ❑
z o re- LicenClass Lic.Number
C, ate__�re/yy���Contractor o(>__�_�
a m 2 c BUILDING PERMIT
¢ ¢ ww o OWNER-BUILDER DECLARATION INFORMATION a I hereby afflunt that I am oxelnpt from the CnNmetoh License MISC.- REFER TO ORD
u. m VALUATION $/FT.
H =o j Law for the Ibllowing roasml.(Set 7031.5,Business and Profesaons PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter, �,��
QK Q Q improve,lI L`mO115I1,Or repair lllly SHnCHIfe,prior to its issuance,aI30 ELEC.CONTR. LIC.N0. ELEC.
O LL requires IIIc applicant for such permit 10 file a signed statement that TOTAL PERMIT TO
n w m he is licensed pursuant to the provisions of the Contractor's License
i Law(Chapter 9(commencing with Section 7000)of Division 3 ofthc
2 a Business and Professions Code)or that he is crcempt therefrom and CITY. PLUMBING PERMIT FEE
IS r m the basis for tiro alleged exemption,Any violation o1'Section 7031.5 gq STORIES TYPE CONSTR.
i ; - by any applicant for a pemlit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00 fY
of not more than five hundred dollars 0500).):
❑ L as owner of the property,or my employees with wages as 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 her sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds of improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himsoll'or
through his own croployors,provided that su ch i"'prdVC
nients re r oroffered
frsthe building
GAS-EA.SYSTEM-11NC.40UTLETS 8.00
ur improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 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 INTER. 30.00 RES IND CON PB Omer
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed cumorctors 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 docs 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 contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft 10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ l amexempt under Sec. ,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACG FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP.
I hereby at that I have a certificate of cunsent W self-tea rc' ZONING ENG.SITE NO.
or a certificate of Workers'Compensationsurce
Inan ,or a Lenified
copy thercoffScc 3800,Lah.C.). r T
Policy No. Company -
O ❑ Certified copy is hereby fur 'lied PL,SLS ,7,9FIRE SPRINK ENERGY T 24
Z
p A Certified ]s,,f�led tai 1 1 coy inspection division. MISC.- REFER TO ORD.. v❑ N❑ Y ❑ N❑
~ w �I T1 PERMIT ISSUANCE 1" C/1.0 FLOOD ZONE A.L.U.C.
LU CIiRTII' EOIr SATION'IFROM WORKERS'
W 7 COh1PEN$e cont INSURANCE ifthe PLG.CONTR. LIC.NO. PLG. Y❑ N❑ Y ❑ N❑
d O (This section need not be completed if the permit is for one TOTAL .�
Z hundred dollars(S100)or less)
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Connpensation Laws ol'California.
O w BUILDING ? b
OL Dam App1m°m ALTER OR ADD TO MECH. 5.00 ✓ `s`_
} to NOTICE '1'O APPLICANT: it,after making this Certificate of Ex-
♦- Z anption,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 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10.CODC.F.M.) 6.00 SEISMIC FEE S�
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
Ore performance of the work for which this permit is issued(Sec. MICROFILM
3097,CivCJ. HEATING UNIT(TO 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 readlhisappticatlon and state that the above VENTILATION FAN (SINGLE) 4.00
® information is correct.I agree to comply with all city and county PLUMBING �Q d21
ordinances and state laws totaling to building construction. and BOILER-COMP(3H.P.or100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP lover 100,000 BTU)SEE FEE SCH. MECHANICAL'
above evotioned property for insPecoon purpoms.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue gains) said City in consequence of the PERMIT ISSUANCE 10.00
granditOF4 this permit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
tgmd pplicant mrador Lae
INSPECTOR COPY