8697 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING
APPLICATION & PERMIT 8697
ADDRESS
11 BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWN PLAN CHECK VALIDATION
"ante 3fta FCuu R.� QTY. ELECTRIC PERMIT FEE
• //PHONE
NONERACTORS A OUTLETS-SWITCHES-RECEP 10.00/1.00
( ilc.rvo. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S - APPLIANCES-RESIDENTIAL 4.00
_PHONE PANELS 10.00 DATE OF APPLICATION
C o PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.N0.
OR
ENGINEER
LIC,NO, SIGNS TRANS. 3.00
AR H.Ess ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
zIP EMP.METER OR POLE INS. 20.00
APPLICANT MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
U I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
V G m (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F H z Professions Code and my license is in full force and effect ❑ ❑ El 1:1z O m - License Class Lie.Number
o m -o Date Contractor
F - r
a x BUILDING PERMIT
Is rt w a OWNER-BUILDER DECLARATION
A o a D INFORMATION
w 3 u. w I hereby'affirm that 1 am exempt from lite Contractor's License MISC.- REFER TO ORD
F l. oj Law for the following reason, 7031.5,Business and Professions pERMIT ISSUANCE 10.00 VALUATION $/FT.
Code:Any CLYDE county'which requires a permit to construct,alter,
EEa¢o improve,demolish,ar repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
o in requires the applicant for such permit to file a signed statement that TOTAL
a w m w he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
FZQ
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe /0`8�
z D Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
EE . the basis for the alleged exemption.Any violation ofsnction 7031.5 STORIES TYPE CONSTR,
to dam by any applicant for a permit subjects the applicant too civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP PES.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,AR EA,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 I F IXTUR ES-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-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, - . -
the owner- GAS EASYSTEM OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or am- BUILDING USE
Prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 RES IND CON PB Omer
❑ 1,as owner of the property,am exclusively contracting with . .
❑ 0 ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL Nqu^, '
and Professions Code:The Contractor's License Law does not apply - ..n'e'..,
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to SEWER'-SAN V-STORM EA.2001t/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
Imo exempt under Sea ,B.&P.C.for Ibis reason WATER HEATER W/VENT 6.00
0
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO,
WORKERS'COMPE:NSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a ceniftcate of consent to wit-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No. COECl bly
Q ❑ Certified ropy -by form FIRE SPRINK ENERGY T24
Z 2 {L Certified y is led n ty inspectiun division.
O A¢dficanl J MISC.- REFER TO ORD. YE] N� YE) NE]
Cr y CF-RT 'NPTIO RSMWORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.C.
LU J A1PfiNSATION I NSU ANCE PLG.CONTR. LIC.NO. PLG.
0 (This section need not be completed if the permit is for one TOTAL JAM A A Y Y ❑ NEI
hundred dollars f 51001 or less.)
U O 1 certify that in the performance of the work for which this per- OTV MECHANICAL PERMIT FEE
FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in any manneras to
❑ become subject to the Workers'Compensation Laws of California.r
ED u Datc Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE TO APPLICANT: If,after making this Certificate of Iix-
F 2 caption,you should become subject to the Worker 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 Evoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.EM.) 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 lot 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 S.T.U.)9.50
Lenders Address ELECTRIC
I certify that I have read this application and stale that lite above VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city and county PLUMBING 0�
ordinances and state laws refuting to building construction, and BOILER-COMP(3 H.P.or 100,000B.T.U.) 6.00 l
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,00.0 BTUI SEE FEE SCH. MECHANICAL
abovc,mentioned property for inspection purposes.
(We) agree to save, indei nif EdL,oxt,
harmless the City of MISC.- REFER TO ORD.
Cupertino agar 'ubiliti a renmW expenses which pERMIT ISSUANCE 10.00CONST.TAX
may in a ay ' Cr •Ij1 st saidconsequence of the
gmntin [h'' m{ / MECH.CONT. LIC.NO. MECH.
_ TOTAL TOTAL"
Si Ap ' ant/C n actor Ualc
INSPECTOR COPY
' I