C8299 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
APPLICATION & PERMIT
p ADDRESc P
l;!
ADDRESS
BUILDINGELECTRICAL-PLUMBING-MECHANICAL
C_,A
O N R'S - _ PLAN CHECK VALID ATION
•�( NAMEQTY. ELECTRIC PERMIT FEE
CONTRACTORS
NAME fOUTLETS-SWITCHES-RECEP 10.00/1.00
•'�• t 5 uc.rv0, q1,! LIGHTING FIXTURES 10.00/1.00
CONTRACT R's PPLIANCES-RESIDENTIAL 4.00
A ORFss
/ PRONE PANELS 10.00
/` DATE OF APPLICATION
�L ORRCHITECT PANELS (OVER 200 AMPI 20.00 PLAN CHECK FEE P.C.N0.
O
ENGINEER
Lac.No. SIGNS TRANS- 3.00
ADDRESS Ervc. SPECIAL CIRCUIT 5,66 PERMIT VALIDATION
CIE rrEMP.METER OR POLE INS. 20.00
APPLICANTS
ADOREMOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 C q
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
< I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
I'I Icmome Gnein,with Section 7000)of Dl ami 3 Of the Business and ay BLDG. ELECT. I PLG. MECH.
H A z Professions Code,and my license is in full force a�e�ffe-ctC G� -
Co u, - License Class I' Lia.Number�� � � El 1
Z r t Datc Contractor�I'
a x f BUILDING PERMIT
¢ rc w ¢ OWNER-BUILDER DECLARATION
D d v INFORMATION
X 0 H 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
LL o a - Law for the following reason.(Sec.7031,5,Bu iness and Professions !lam VALUATION S/FT.
_ 1, PERMIT ISSUANCE 1.0-00
Code:Any city or county which requires a permit to construct,alter, -
rc ¢ o improve,demolish,or repair city structure,mcturo,prior to its issuance,also ELEC.CONTR. LIC.NO. FLED.
O ¢ requires the applicant for such permit to file a signed statement that TOTAL eke)
a w m w he is licensed pursuant to the provisions of the Contractors License PERMIT TO
� Z i- Law(Chapter 9(commencing with Section 7000)of Division 3 oldie
P o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT .FEE
¢ H o Ilse basis follite alleged exemption.Any violation ofSeclion 7031,5 STORIES , TYPE CONSTR.
La
A „- by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.)-5.00
of not more than five hundred dollars(S500).):
Cl I,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 for safe (Sea 7044, Business and I'rofes4ons DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an 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-
meats are not intended or offered par sale,If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sdld 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 int- BUILDING USE
prove for purpose of salc.l' INDUSTRIAL WASTE INTER. 30.00 RES o CON PB Omer
❑ I,as owner of the property,am exclusively contracting with - ❑ ❑ ❑ ❑
licensed Contractors to construct Die project (Sec.7044,Business LAWN SPRINKLERS-1 ANC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:'Tic Contract,,,',License Law docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts forsuch projectswith a contraetons)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ tum exempt under See ,B.&I'.C.lir,this. WATER HEATER W/VENT 6.00
,� ostia
Owner Date WATER SYSTEM 5.00 ACC.DATE, , ACC.FILE NO.
W'ORKERS'CONPENSA'TION DECLARATION WATER TREATING EQUIP. 5.00 ,
I hereby affirm That l have a certil'icale of.....sent❑t self-insert. c' ZONING
`/t or a certificate of Workers'Compensation Insurance,ur a certified .r ZONING ENG.SITE NO.
/x_' copy thereof(See.3800,Lab.C� L / io n{'W
Policy No. Company
OX
❑ Certified copy is hereby furnish. . Y,/
FIRE.SPRINK ENERGY T 24
Z Z ❑ Cortil'iud copy ix flied wish the city Inspection division. rr
~ O Applicant MISC.- i REFERTOORD. Ij Y I N❑ r ❑ NNE]
2 w CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT'ISSUANCE 1 FLOOD ZONE A1.U.C.
UJ > COhIPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG, W
CL 0 CL Z (This section need not be completed if the permit is for one TOTAL a'(a Y❑ N[_ Y ❑ N❑
hundred dollars IS I00)or less.)
U O I certify that in the performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mil is issued,I shall not employ any person in any manner sit as to
become subject to the Workers'Contpenmtion Laws of California.
DO O a Late Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE'TO APPLICANT: If,after making this Certificate of Ex-
Z_ cntption,you should become subject to the Workers'Compensation APPLIANCE 5.00 ,rAT; PLAN CHECK ,
provisions of the Labor Code, you must forthwith cont..ly with FEE -
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LI?NDING 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 i
the performance of the work for which this permit is issued(Sec MICROFILM
3097,Civ.CJ, HEATING UNIT(TO 100,000 B.T.U.)' 8.00
Lender's Name HEATING UNIT ER 100,000 B.T.U.)9.50 av
Lender's Address 1 ELECTRIC
I certify that 1 have read this application and state that the above VENTILATION'FAN (SINGLE) 4.00
® in I'ounation is correct. I agree to comply with all cfly
and county PLUMBING / I�
ordinances and state laws relating to building construction, and BOILER-COMP(3H,P.or100,000B.T.U.) 6.00 /
hereby authorise representativesertrns inspection
this city to safer upon the BOILER-COMP (Over 100,000 STU)SEE FEE SCH. MECHANICAL
hereby
act
have-mentioned properly forinspection puity
(WC) agree to save, indemnify and keep lurnaless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs mW expenses which PERMIT ISSUANCE 10.00 rR CONST.TAX
may in any way accrue against said City in consequence of the
granting of this permit. MECH.CONT. LIC NO. MECH.
> �re of Applicant/ on�ac[or Date � >r TOTAL fes- TOTAL �� C-•
INSPECTOR OPV �.-._