8361 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT.I DENT[FICATI ON PERMIT NUMBER
BOLLD,NG APPLICATION & PERMIT
ADOREss ((��^(��I
0 C BUILDING -ELECTRICAL-PLUMBING -MECHANICAL - 8S SPS 1
OWNER'$ - - - PLAN CHECKVVALILIDIAATItttON
ONAME y�/,•�•"�� t� //' /L// S QTY. ELECTRIC PERMIT FEE
NAME AcroRs OUTLETS-SWITCHES-RECEP UL00/1.00
LC,NO LIGHTING FIXTURES 1D,00/1.00 <-c,"d `
ADDRESSrons
ADDRESS APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
oncHrrecr PANELS (OVER.200 AMPI 20.00 PLAry CHECK FEE P.c.No.
ENGINEER
uc.ND. SIGNS TRANS. 3.00:
' ADDRESS ENO SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
Ar$
ADDRESS MOTORS SEES FEE SCH. .CN I
DRESS E55 / (r(
SERVICE CHANGE ,i 20.00
oo LICENSED CON TRACTORS DECLARATION TEMP.POLE .r' 30.00 ((
an i p I hereby of hrmthm Gnsad
on on Business an
at 1 aceunder provisions of Chapter 9 P ISSUANCE DATE
(commencing w
p1 ( miith Secti7000)Of Division 3 of the Busid
ri. a N E
H N z Professions Code,and my license is in full force and effect BLDG. LECT. PLG. MECH.
❑ ❑ ❑ ❑
� 0 O m.- License floss on Number
4 w t Date Contractor -
a Y - - BUILDING PERMIT
Eso a OWNER-BUILDER DECLARATION INFORMATION
w3LL v, I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
Fu Oj Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 1I).QQ W VALUATION $/FT.
Code:Any city or county which requires a permit to construct,eller, //Q
¢ ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. ry �� T' y 0O O
n w Om a requires the applicant for such permit to file a signed statement first 1 TOTAL �U r PERMIT TO
he is licensed protocol to the Provisions of the Contractor's License
i
Lilly(Chapter 9(commencing with Section 7000)of Division 3 offe
i o Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE �ti T�RKU� C=Mtl'
¢ H o the basis for the alleged exemption.Any violation of Section 7011,5 I STORIES TYPE CONSTR.
a ;To by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER, (EA.) x.00
of not more than five hundred dollar, $5001J'.
❑ 1,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 tire work,and the structure is not
intended or offered for sale (Scc. 7044- Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PERTRAP 5.00 SQ.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that suchinlpr.,c-
encs are not intended or offered for sale.if,however,me 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 proving that he did not build or inn BUILDING USE
Prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB other
hr��yy I,as owner of the property,am exclusively contracting with D El El El ElP ell contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6-00 ASSESSORS PARCEL NO.
add PH fCSSIOns Code:The Contractor's License Law does not apply
to an owner of property who builds or innproves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec. B.&P.C.for On WATER HEATER W/VENT 6.00
reason �. �7
Owner t Datd'�-�fflWATER SYSTEM. 5.00
ACC.GATE ACG FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm Ihm I have a certificate ofconsent to self-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.CJ.
Policy No. Cmnpany
O ❑ Certified copy is hereby furnished- P FIRE SPRINK ENERGY T-24
z Z ❑ Certified copy is filed with the city inspection divieiah. MISC.- REFER TO OR D. Y.0 NE] YE] NE]
0 Applicant 1,: ,
~ w PERMIT ISSUANCE 1
- CERTIFICATE OE&EMPTION FROM WORKERS' - FLOOD ZONE A.L.l1.C.
LU > COMPENSATION'INSURANCE PLG.CONTR. LIC.NO. PLY ,
(This section need nalbe completed if the permit is for one TOTAL �2 Y❑ N Y N
hundred dollars IS 100)or I...)
U O _ I certify that in tire performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
EL F- alit is issued, I shall not employ any person in any manner so as to ry
U w become subject to the Workers'Compensation Laws of California.
Date A licant BUILDING OT 0'n
a vn ALTER OR ADD TO MECH: 5.00
> m NOTICE TO AfPLICAN'1'. If,after making tlhis Cerlil icatc of 8x-
cmption,you should become subject to the Workers'Compensut ion APPLIANCE 5.00 PLAN CHECK '
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permm
it shall he deemed revoked. AIR HANDLING UNIT(TO 10DOOCF.IVL) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE O !')
I hcmby affirm that there is u construction lending agency for EXHAUST HOOD(WITH DUCT) U0
the performance of the work for which this permit is issued ISec. MICROFILM
�r
3 . HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender,n1a,,'s Name e HEATI NG UNIT 100,000 B.T.U.)9.50 a.0 CN
Lender's Address ELECTRIC
1 certify that 1 have read this application and state that Be
above VENTILATION FAN (SINGLE) 4.00
information is correct.I agree to comply with all city and county BOILER-COMP(3 H.P.or400,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building conslmetion, and
hereby authorize representativesofthis city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL - W
about-mentioned property for inspection purposes.
(We) agree to savti indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 1 CONST.TAX
may in y-way ace against said City in consequence of the �0
grant of th,�4A��p_fit. n MECH.CONT. LIC.NO. MECH.
1.,4 .9 t9, s,_a� �9 9i TOTAL tf TOTAL. �C�cf S
J' Sign atuun5off Applicant/Contractor Date
INSPECTOR COPY