8704 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 �y O
AODR s
r BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
Ow E PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
P.ON -
NAME CTD" OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO, LIGHTING FIXTURES 10.00/1.00
r. TRACTDRs APPLIANCES-RESIDENTIAL 4.00
ADDR E55
F ONE PANELS 10.00 DATE OF APPLICATION
OR ° PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.N0.
ENGINEER
LIC.ND. SIGNS TRANS., 3.00
ARCH.
DD ESS Ervc' SPECIAL CIRCUIT 5.00 PERMIT vnu DATION
ZIP EMP.METER OR POLE INS. 20.00 ("01.-
AvvucArvrs MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
0 LICENSED CONTRACTORS DECLARA]TON TEMP.POLE 30.00
a U u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
mi (commencing with Section 7000)of Division 3 of the Business and
G BLDG. ELECT. PLG. MECH.
H m i Professions Code,and my license is in full force and effect. ❑ a ❑ ❑
z O m -'7.License Class Lia Number 7 J M Q? C/
g a / DateCun tract., 's�-7- (� -
a y E ( BUILDING PERMIT
¢ ¢ cOWNER-BUILDER DECLARATION
¢ w
K
;LL y I hereby affirm that I am exempt from the Coutmetor's License MISC.- REFER TO ORD k
.. o A Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 19:00 VALUATION S/FT.
Code:Any city orcounty which requires a permit toconstruct,alter,
Q¢improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
Le A m LL requires the applicant for such permit t.file a signed statement that TOTAL PERMIT TO
w he is licensed pursuant to the provisions of the Contractor's License
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe -
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE Ft a E�C7
¢ r p the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
y „- by any applicant for a permit Subjects the applicant toa civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(S500LL
❑ I,as owner of the property,or rey 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 for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code 1'he 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 SOLFT.FLOOR AREA TOTALACREAGE
• himselfre or ugh intends ownemployees,for sale.
if,hJihmsuch improve- GAS-EA.SYSTEM-1 6.00
mans are not intended or offered foe sole.If,however,the building
or improvement is sold within one year of completion,the owner- r GAS-EASYSTEM-OVER 4 (EA.) 200 BUILDING USE
builder will have the burden of proving that he did not build or it. . . .
- RES IND CON PB Other
prove lot purpose of sale.)' INDUSTRIAL WASTE INTER. 30.00
❑ I,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 r• 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 wile, LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts fur such projects with a contract.rts)licensed pursuani to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. / TRACT NO. PARCEL NO.
- ❑ Iumexemptunder Sec. ,BAP.C.for this WATER HEATER W/VENT 6.00
rt�so
Owner ])life WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKI;kS'COMPENSAnON DECLARATION WATER TREATING EQUIP. 5.00
I hereby uffinm that I have a certificate ,I consent to self-insme, ZONING ENG.SITE NO.
or a cerat
tifice of Workers'Compensation le,uruncc,or a certified
copylhereof(Sca380 Lab h
Policy NU.
O ❑ Cenifte eby trusted. ��00 �(� RE SPRINK ENERGY T@4
Z Z ❑ Certified copy is filed with the city in`sPaD division.
~ p Applicant MISC.- REFER TO ORD. YE] No Y ❑ No
- to PERMIT ISSUANCE 10.00
CERTIFICATE OF EXEMPTION I7RONI WORKERS' FLOOD ZONE A.LU.C.
W i COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y❑ N❑ v❑ N❑
CL Z ('Phis section need not be completed if the permit is for one TOTAL
hundred dollars(5100)or IessJ
U Q I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued, I shall not employ any person in any manner so as to
O L) become subject to the Worker Compensation Laws of California.
D. Dale Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>_ W NO'I WE 1'0 APPLICANT: If,after making this Cenif' at
ice of Ex-
F Z emption,you should become subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must lihrthwith comply with FEE
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10)"C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.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
Lender's Address HEATI NG UNIT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00
int.nnation 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.Or 100,000 B.T.U.) 6.00
hereby autHoi,o representatives of this city m enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-nuenlioned property for inspection purpuras.
(We) agree to sav i emnify and keep harm) City of MISC.- REFER TO ORD.
Cupertino against hit' judgments, costs uses which CONST.TAX
nmy in any w ace con:qt ce of the PERMIT ISSUANCE 10.00
granting of pen MECH.CONT. LIC.NO. MECH.
[� TOTAL TOTAL
S' Btu eofA
ph ant/ on ac Uafe S
/ INSPECTOR COPY