8722 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
AUDORENG APPLICATION & PERMIT 87^2
aooREss G
ax I UILDING - ELECTRICAL-PLUMBING-MECHANICAL
W rl PLAN CHECK VALIDATION
"NAM QTY. ELECTRIC PERMIT FEE
. RS
NAMERA ° 9A31 UTLETS-SWITCHES-RECEP 10.00/1.00
Lie,NO, LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S
ADDRESS APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
UC.No, SIGNS TRANS. 3.00
ARCH.ss ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDREZIP TEMP.METER OR POLE INS. 20.00
ADDREsESNra
appRMOTORS 1 SEE FEE SCH. S
s
SERVICE CHANGE 2000.. C'•
,-00 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 - fauf
Q u v I hereby allirm that I am licensed under provisions of Chapter 9 ISSUANCE DAT
a z a (co nciencin with Section 7000)of Division 3 of the Business and
a g BLDG. ELECT. PLG. MECH.
r o i Professions Code,and my license is in full force and effect. El ❑ El
❑
License Class Lia Number
o r DaW Commctor
¢ Y E BUILDING PERMIT
¢ a W
¢ ¢ ONER-BUILDER DECLARATION
ec o INFORMATION
wr$ -
g ou a, I hereby affirm that I am exempt front the Contractor i License MISC. REFER TO ORD
FU0< Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 1 (fa VALUATION S/FT.
Code:Any city or county which requires a permit to construct,alter, -
¢ 2 ¢ 0 improve,demolish,or repair any structure,prior to its.issuance,also ELEC.CONTR. LIC.NO, ELEC.
O¢ requires the applicant for such permit to file a signed statement that TOTAL /6 PERMIT TO
a w m m he is licensed pursuant to the provisions of the Contractor's Licgrlsc
F z r Law(Chapter 9(commencing with Section 7000)of Division 3 o(the
¢ a Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE LeL
.the basis for the alleged exemption.Any
" ¢ fe g pviulation nl$ccfion 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN& VENT-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 DCC.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,GOND. 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 inrinowc-
ar
.,cuts e not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is Bold within one year of completion, - . .) 2.00 the owner- GAS EASYSTEM-OVER 4 (EA
builder will have the burden of pronng that he Aid not build or int- BUILDING USE
prove for purpose of sale.). m
INDUSTRIAL WASTE INTER. 3000 RES IND CON PB Oar
❑ I,as owner of the property,am exclusively cmumeting with . ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044, Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Cods:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPR INKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I amexempt un der Se c. ,B.&P.C.for Itis WATER HEATER W/VENT 6.00
eason
Owner WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DI:CLAlj{aZQA rF T WATER TREATING EQUIP. 5.00 '
1 hereby affirm that I have a Certificate of consent m scl Linsure' ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insutmmc.or a certified
copy thereof(Sec.3800,Lab.C.). 0
m
I Policy No. Copany -
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T$4
z Z ❑ Certified copy is filed with the city inspection division.
0 Applicant MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
Cr rn CERT WICA'11:OI'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOOZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y❑ N❑ V E] N❑
CL Z( Phis seclion ecd not be completed if the pe nn it is for one TOTAL
hundred dollars IS 100)or Tess.)
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is inued,I shall not en.ploy any person in:my manner so as to
O W become subject to the Workers'Compensation Laws of California. BUILDING
a
Date-Applicant ALTER OR ADD TO MECH. 5.00
} m NOTICE '1'0 APPLICANT: If,after making this Certificate of Ex-
F 2 emptimn,you should become subject to the Worker Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoker$. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 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 for which this permit is issued(Sec MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)9.50
Lancer's Address ELECTRIC ZKI
Q•�
1 certify that I have read this application and slide than the above VENTILATION FAN (SINGLE) 4.00
• infannation is correct. I agree tcomply with all city aid county 00 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
omn
inans and Mule laws relating
m ng building construction, and,
hereby auotorire representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purpow%.
(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 accrue against said City in consequence of the
gran of permit/� '/f MECH.CONT. LIC.NO. MECH.
TOTAL
9,. YYYfI' n /�J TOTAL
Xant Cont ae� Date
INSPECTOR COPY