8443 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT 1 DENTIN CATION PERMIT NUMBER
EDILOINc APPLICATION & PERMIT
PDORE55 BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 8443
O NER
PLAN CHECK VALIDATION
NAME QTYELECTRIC PERMIT FEE
. D C PHONE
.
CONTRACTOR'S
NPME �1 UTLETS-SWITCHES-RECEP 10.0(1/1.00 i
LIGHTING FIXTURES 119,001100 ��.
CONTRACTOR'S. APPLIANCES 4.00'
AooREss �p�!�
PHONE PANELS 10.00 Q DATE OF APPLICATION
ORCHI cr PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.No.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENc. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP. METER OR POLE INS. 20.00 .
ADDRESS rs
ADDRESS MOTORS SEE FEE SCH.
J
SERVICE CHANGE 20.00
o 0 0' LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 f//a `
Fvu L,w 1 hereby affirm that I am licensed under provisions of Chapter 9 {t ISSUANCE DATE
Q N (Commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H H z Professions Code,and my license is in full force and effec ,D $-U ❑ ❑ ❑
Z D y -O/ License Class I Number
o v, ` Dair- a�(j Contractor (n /O /7�P,
71!.4n SF, 7,(-/<VA- BUILDING PERMIT
¢ o ac a U OWNER-BUILDER DF-CLA RA TION INFORMATION
E:
3 LL H 1 hereby affirm fit 1 am exumpl from the Contrucmr's License MISC.- REFER TO ORD
F LL D J Luw for the following reason.(Sec.7031.5,Business and 1'Inl'cssinns PERMIT ISSUANCE 10y00 VALUATION $/FT.
wv, Code',Any city or county which requirese Permit tocanslmcl,aller,
2 ¢ op improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.N2 ELEC.
¢ requires the applicant for such permit to file a signed sl:denient that TOTAL old
PERMIT TO
d w m u he is licensed pursuant to the provisions of lire Contractor's License
Fri
Law(Chapter 9(commencing with Section 7000)ofDivision 3 of the
a Business and Professions Code)or that he is exempt therefrom andCITY. PLUMBING PERMIT FEE
sio
¢ H o
the basis for the alleged exemption.Any violwion of Sect ion 7031.5 STORIES TYPE CONSTR.
a ;m by any applicant for n permit subjects tine applicant to a civil penally
of not more than five hundred dollars(S500).): ALTER-DRAIN& VENT-WATER (EA.) 5.00
❑ 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 sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Lay.'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 i 1prove-
menlsarenot intended or offered for sale.IL 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 IEA,) 2.00
builder will have the burden of proven,that he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON Pe Other
❑ 1,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 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law docs ool apply
to un owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractor(s)licensed pursvanl to
Ihu Contractor's License Law. I SEWER-SANITARY-STORM EA.200ft/10.00 TRACT No. PARCELNO.
❑ (sun exnupl under Sec ,B.&P.C.An this WATER HEATER W/VENT 6.00
rCa\nll
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE N0,
WORKERS'COMPENSATION DECLARAT'ION WATER TREATING EQUIP. 5.00
i
1 hereby ate of that I have a certificate of consent to or
censure ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy lhereof(Sec.380 Lab.C.).
O ••e � LbP r�i�e� y d
Ctl dcopY fisher Yfurnrh FIRE SPRINK ENERGY T 24
z_z ❑ Certirkrdgopy is fill with the city inspection division. MISC.- REFER TO ORD.
0. Applicant Y❑ N❑ Y ❑ N❑
cc - CER'1'IP1CA'1'I$ Is R.471 F-I OM RKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE AL.U.C.
W > COMPCNSATION IN URANCE PLG.CONTE. LIC.NO. PLG.
CIL O ('Ibis seclion need not be completed if the Permit is for one TOTAL Y❑ N❑ Y❑ N❑
:) Z hundred dollars IS I 00 or less.)
U O 1 certify thin in the performance of Ore work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- (nit is issued,I shall not employ any person.in any manner so as In -N
O w become(abject to the Workers'Com,cnsa Gun Luw,of California.
y Datn Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE 10 APPLICANT: If,after making this Certificate of nix-
(_ Z clnption,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 Inch provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1QOW C.F.M.1 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE
I hereby affirm Ilml 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 HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC 3
I certify that l have read this application and state that(he above VENTILATION FAN (SINGLE) 4.00
• information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMM H.P.Or 100,000 B.T.U.) 6.00
hereby authorial representatives of this city to enter upon the
abovc-mentinneA properly for inspection urposes.
BOILER-COMP (Over 100,000 BTU(SEE FEE SCH. MECHANICAL
p
(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 neem against said City in consequence of the
gra 'go (his amiL - - MECH.CONLIC.N0. MECH.
1 14 TOTAL TOTAL
ignatureo A Iica n[ ctor fe
INSPECTOR COPY