8725 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIF I CATION PERMIT NUMBER
aOILDING APPLICATION & PERMIT
ADDRESS S 8725
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
NAME PLAN CHECK VALIDATION
' NAME QTY.
NAME ELECTRIC PERMIT FEE
• PHONE
RS UTLETS-SWITCHES-RECEP 10.00/1.00
LIc.No. LIGHTING FIXTURES 10.00/1.00
ADDRESS PPLIANCES-RESIDENTIAL 4.00
_ I VPIPYE - PANELS IO.00 DATE OF APPLICATION
OR ED PANELS (OVER 200 AMP) 20.00 PLAN CWEEZ77 P.C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH.OR ADDRESS ENG. SPECIAL CIRCUIT 5.0B PERMIT VALIDATION
APLICFNT'S ZIP EMP.METER OR POLE INS. 20.00 (/�/'J/�'))�'�\.- ,.
PV �C .
ADDRESS MOTORS SEE FEE SCH. ` J
SERVICE CHANGE 20.00 i
, 00 O o LICIiNSCU CONTRACTORS DECLARATION TEMP. POLE 30.00
a v C, I Imreby affirm that I wn licensed under pr.vislons of Chapter 9
H a N (commencing will,Section 7000)of Division 3 of the Business and ISSUANCE DATE
BLDG. ELECT. PLG. MECH.
F m z Professions Code,and my license is in full force'nd effL,l _ •et._ ❑ ❑ ❑ ❑
Z o w - Lic'a Cla s Lia Number '��'�-.-��-
ow r w� Dale Contractor
a Y DECLARATION
BUILDING PERMIT
OE
u OWNIi R-NUILUIiR DECLn RATION INFORMATION
R
;u H I hereby affirm thm I an exempt from the Contract.,',LicensC MISC.- REFER TO ORD S -
Fuoj Law for the following rca,on.(See.7031.5,13usincssand lb.l'e"ions PERMIT ISSUANCE10 0 ^ VALUATION $/FT.
Code:Any city or county which requires.permit to construct,alter,
mQ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
1requires the applicant fur such permit to file a signed statement that - TOTAL rL- PERMIT TO
w m Ile is licensed pursuant i.Ihe provisions of the Contractor's License
r ¢ Q
Law(Clmpter9(canmmocingwill,Seeli...7000).1Division 3 of the TSP
4 D Business and Prolessions Code)or tmt he is exempt therefrom and
w F o the basis for tire oluged exemption.Any viuhhlinn of OTV. PLUMBING PERMIT FEE Section 7031.5 STORIES TYPE CONSTR.
by any applicam(try apermit subjects the applicant to a civil penally ALTER-DRAIN -WATER (EA.) 5.00
of not more than five Imndred dollars(8500).):
❑ I,as owner of the property,or my employees with wage,as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compenwion,will do the work,and the sl Preto re is not
intended or offered for sale (Sec. 7044. Business and Professions 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 50.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
or improvement is sold within one year of completion,tire owner-
builderwill have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose ofsme.). INDUSTRIAL WASTE INTER3000 RES IND CON PB Omar
. .
❑ 1,as owner of the property,am exclusively contracting with 11 0 ❑ ❑ ❑
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 does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OV ER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to.
the Contractor's License Law. SEWER-SAN ITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
0 lam exempt under Sec.-,B.&P.C.for this
reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO,
WORK Ii RS'COMPENSA'I'ION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a CeRil irate c consent to self-insure.
or a Certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(See.3800,Lab.C.).
Policy No. Company
07
❑ Certified copy is hereby fun.
Z Z QiC'vu ified ropy is fled will, the city inspection divisionllf� n. FIRE SPR INK ENERGY T-14
F O� Ao <ant � -�'erq MISC.- REFER TO ORD. Y � NEJ Y � N�
N CER1'IFICATIi OIs Ii XIiMPI'ION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.UL.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
a_ Z (Phis section need not be completed if tire
e permit is bar one TOTAL Y E] NC] Y El NEI
hw.dred dollars 1$100)or less.)
U _O 1 certify ilia, in the performance of the work I'or which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall not enhplo,any Person in any mmmcr so as to
Ow
hccome subject to tho , m
W.rkC, Copensation U.,of Cdifonlia.
ED Date Applicant BUILDING
to NOTICE TO APPLICANT: II',after making this Certil'icalc of Cx- ALTER OR ADD TO MECH. 5.00
FZ Cmpro.,you should benne,abject to the Wo,keo'CmnpensaUon APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you nwsl torthwilh comply with FEE
U such provisions or this permit shall be decnmd revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AG17NCY AIR HANDLING UNIT(OVER 10000GEM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the perp rmanee of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.E HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Leader's Address -`- ELECTRIC
I C,Hhly That I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 r
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COUP(3 H.P.or 100,000 B.T.U.) 6.00
herebyentiond ropretyforiins•o(on city toenter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection this
purports.
(We) agree to Sive, 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 accrue against mid City in consequence of the
granting of this permit MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
crgmrRzrmvM,P11 VI al V
INSPECTOR COPY