8721 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
`, BI,ILnINo n APPLICATION & PERMIT
K AooREss
8721•1. X1.,1 1 BUILDING -ELECTRICAL-PLUMBING -MECHANICAL
OWNER'R \J PLAN CHECK VALIDATION
_r• NA E QTY. ELECTRIC PERMIT FEE
HONE
•.
CON[TRACTOR
NamEOUTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.60/1.00
r, NTR CTORSI 1 APPLIANCES-RESIDENTIAL 4.00
x ADDRESS 419
a+EL!5:7-2
7 PANELS 16.00 DATE OF APPLICATION
OR RCHITET PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
O
ENGINEER
' uc.NO SIGNS TRANS- 3.00
nooeEss ervc. SPECIALCIRCUIT 5,00 PERMIT VALIDATION
nP EMP.METER OR POLE INS. 20.00
AvvucArvrs MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
o o• • LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a o u 1 herchy affirm that I am licensed under provisions of Chaplcr 9 ISSUANCE DATE
m a w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG, MECH.
D Z Professions Code, hd m I' en se is in full force and ElElEJz o y - License ClassLic.Number
o o
Date d-7- Contractor
a Y E '�( - BUILDING PERMIT
¢ o )WNER-BUILDER DECLARATION INFORMATION
wS LL 1 hereby affinn that 1 ren exempt from the Contractor's License MISC.- REFER TO ORD
.c U- Law for Orn following reason. 7031.5.Businessand Professions PERMIT ISSUANCE In nq W VALUATION $/FT.
in Code:Any city or county which reyuirm a permit to construct.alter,
rt ¢0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE LIC.NO. ELEC. J
re
iL m LL requires the applicant for such permit to file a signed statement that TOTAL �O/. � PERMIT TO
w he is licensed pursuant to the provisions of the Contractor's License
F z a Law(Chapter9(commencingwith Section 7000)olDivision 3 offle
4 o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ I_e the basis for the alleged exmmption.-Any violation of Section703 t.5 STORIES TYPE CONSTR.
n ;m
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than Ove hundred dollars(3500).).
❑ I,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 lire work,and the structure 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 so.FT.FLOOR AREA TOTALACREAGE
• himself'or turned, his own cmploy,,s,Provided thi t suchimprove-
meets are not intended or oR'arcd for sale.If,however,the budding GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM.OVER 4(EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
v prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 RE5 IND CON PB Other
. .
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
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-OVER 5(EA.) 1.00
contracts tor such projects with a cuntractorls)licensed pursuant to '
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
z
reason❑ Iain exempt under Sec. .B.&P.C.for this
WATER HEATER W/VENT 6.00
Owner Dale WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKS RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm lhaCl have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof1Sec.3800,Lab.C.T
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-74
Z_ Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y ❑ N❑ Y ❑ No
~ rn PERMIT ISSUANCE 10.00
fr - QiR'1' PICA'TIi CNSA1iION ION FROM WORKERS' FLOOD ZONE A.L.U.C.
lL needC0Nutbe ore INSURANCE PLG.CONTE. LIC.NO, PLG. Y❑ N❑ Y❑ N❑
D Z hundred
section need not be completed if the permit is for one TOTAL
hundred dollars($10000,Icss.)
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issue I sh II not emPloy an Pecan in any manner so as to
Wmnc co 1 t rkcn' I " n Laws of California.
a Date e. - p Pp1'ea"tA 0 4BUILDING
ALTER OR ADD TO MECH. 5.00
} m NOTI A CANT. a in• tui. c tiftcatc of Ex-
F Z
,you should become sndip, 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 10;WC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.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,C1v,C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)Lender's Address ELECTRIC a 0.0
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• information is correct.1 agree to comply with all city and county PLUMBING
ordinances and state Iuws 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
above-mentioned property for inspection purposes, BOILER-COMP(Over 100,000 BTUI SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against It ilities,judgments, Costs and expenses which CONST.TAX
may in any way -c if against said City in consequence of the PERMIT ISSUANCE 10.00
til ufthispert i MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
hro
Sig afore 0 pplic n /Co c or Da
INSPECTOR COPY