8480 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
13U LDING PROJECT I DENT[FI CATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
k ADDRESS
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL - 8480
OWNER' PLAN CHECK VALIDATION
.y- NAME PHONCITY. ELECTRIC PERMIT FEE y/��4
/-'
./ E S_d
NAME f OUTLETS-SWITCHES-RECEP 10.00/1.00 U
Lt. No. LIGHTING FIXTURES 10.00/1.00
;
ADDRESS
o s' PPLIANCES-RESIDENTIAL 4.00. REss
044.fw PHONE' .z PANELS 10,00 DATE OF APPLICATION
ARA T
OR PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.N0.
ENGINEER
_ 1 IC.No. SIGNS TRANS. 3.00
ADDRESSnd+. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
JIt a,
n . . to ZIP EMP.METER OR POLE INS. - 20.00
ADDRESS "
AAry s - MOTORS SEE FEE SCH.
OR
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
M U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
yw (commencing with Section 7000)of Division 3 of the Business and
a y BLDG. ELECT.I PLG. MECH.
F w z Professions Code,and my license is in full force and effect.
z 0.4 - License Class T 1 Lia Number 4 l I$fi ❑ ❑
o Dale Contractor
a >< E -+ BUILDING PERMIT
ac ¢ a OWNER-BUILDER DECLARATION
o d U MISC.- REFER TO ORD INFORMATION
X g LL I hereby affirm that 1 and exempt from the Conlmelor's License
G VALUATION $/FT.
LL D a Law for the following reason.(Sec 7031.5,Businessand Professions PERMIT ISSUANCE 10.00
m Code:Any city Or county which requires a permit to construct.alter, Q C1
¢ a 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTH. LIC.NO. ELEC. �/ vQ '
ou
- D ¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO /
A w m he is licensed pursuant to the provisions of the Contractor's License
H z i Law(Chapter 9(commencing with Scmion 7000)of Division 3 ofthe Z G4i�
a Business and Professions Code)or that he is exempt therefrom and
the basis for tire alleged exemption An DTV. PLUMBING PERMIT FEE Q F
¢r D
oy s'iol.tim of Scction 7031.5 STORIES TYPE CONSTR.
dra g p am _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00 {✓/V
of not more than five hundred dollars(5500).1:
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECTDEV ICE 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,AR EA,CONE). 5.00
'Code:The Contractor's License Law does not apply to an owner of S"
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SO.PT,F LOCH AREA TOTAL ACREAGE
• himself or through his own employees,provided that such""Prove-
novels or eets are not intended u fl'eed pt sale.If,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 (EA.) 2.00
builder will have the burden of proving that huilde did not juridic,int- BUILDirJG USE
prove for purpose ofszleJ. STRIAWASTE INTER. 30.00 RES IND CON PB Olhe,
INDUSTRIAL❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
Mnsed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO,
Professions Cade-.The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00 3 O
contracts for such projects with a contractons)licensed pursuant to SEWER-SANITARY-STORM EA.200fE/10.00
the Contractor's License Law. TRACT NO. PARCELNO.
❑ IIIfllexemPtlmdc,Sed ,B.&P.C.tit this WATER HEATER W/VENT 6.00
mason
Owner _ Date WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO.
WORK ERS'COMPENSA I ION D17CLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-itrane' ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.). / v
Policy N'o. Company-f , ..-
O ❑' Certified Copy is hereby lurmshed FIRE SPRINK ENERGVT-24
Z 2 ❑ Certified copy u tiled with the city inspection division. -
p�" APPlicant�.£rtcn i MISC.- REFER TO ORD. Y❑ N❑ v ❑ N❑' �=
PZ:
PERMIT ISSUANCE 10.00
CC CERTIFICATE OF I XEMPFION PROM WORKF'RS' FLOOD ZONE A.L.0 C.
LU > COMPI!NSATION INSURANCE _ PLG.CONTR. LIC.NO. PLGCL 0 .
�.2 1'lhis Gtel ion need not be completed if the pennit is for one TOTAL Y ElN❑ Y [:] IND
ndred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per, CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
ED
Dale Applicant ALTER OR ADD TO MECH. 5.00 BUILDING n r
} N NOTICE TO APPLICANT': If,after making this Certificate of Ex-
F 2 emplion,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• such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10SWC.F.M.) 4.00
CONS'T'RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency I'or EXHAUST HOOD (WITH DUCT) 5.00
the peffonnance of the work lit 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.)Le,der's Address \,E LE CTRIC
1 certify that I have read this application and state that the 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-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP Over IOO,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree Save, indomnify P Beep harmless lire City of MISC.- REFER TO ORD.
Cupertino ug'I at liab� s,jird cots, costs and expenses which CONST.TAX
may in an way Uan5c/r agai said City in sequence of the PERMIT ISSUANCE 10.00
gr:udiing this p�I. MECN.CONT. LIC.NO. MECH.
l� i TOTAL TOTAL /0 ti
Sign' are o Applicant/ odtractor Uale
INSPECTOR COPY