8727 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FI CATION PERMIT NUMBER
ILS BUILDING APPLICATION & PERMIT
'
ADDRESS 8727
BUILDING —ELECTRICAL—PLUMBING—MECHANICAL
OWNER 5 PLAN CHECK VALIDATION
NAME
QTY. ELECTRIC PERMIT FEE
ONE V
ON RFCT 5
•� OUTLETS 10.00/1.00
NAME �46ZLo7
LIGHTING FIXTURES 10.00/1.00
NTRA j •
ADDRESS
A , PPLIANCES-RESIDENTIAL 4.00 '
A
PHONE PANELS 10.00 DATE OF APPLICATION
OR HrtE r PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO,
ENGINEER
Lac.NO. SIGNS TRANS. -3.00
ARCA Ess END SPECIAL CIRCUIT S.QQ PERMIT VALIDATION
zav EMP. METER OR POLE INS. 20.00 ^ ^
APPLICNrS MOTORS SEE FEE SCH.
ADORDDR ESEss
SERVICE CHANGE 20.00
0 0 o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 jam"/OJ
<
SSS/I hereby affirm dust I en licensed under previsions of Chapter 9 I5 DANCE DATE
(commencing with Section 7000)of Division 3 of the Business and
a A BLDG. ELECT. PLG. MECH.
� y i Professions Cod} J m icense is in full force as �e �n7
z D m - License Class//__ - Lic.Number, ❑ ❑ ❑ ❑
ov, w Date 4- Contractor
a se E U` BUILDING PERMIT
¢ ¢ a WNER-BUILDER DE
¢ w u INFORMATION
w ;e N 1 hereby affirm that I am exempt from the Contractor's License MISC.— --REFER TO ORD
LL o a Law Rrr the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE / 10.00 VALUATION S/FT.
Code'.Any city or county which requireBa permit toconstrucLalter,
¢ Q 0 improve,demolish,or mpair any structure,prior to its issio nes,also ELEC.CONTR. LIC.NO. ELEC.
u w m u requires the applicant for such permit to file a signed statement that - TOTAL PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License
H z 1 Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Profession,Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE 1048
¢ $ the basis for the alleged exemption.An
BC 0 he violation tSection]03L5 STORIES TYPE CONSTR.
by any moctita fora permit subjects the toacivilpenalty ALTER-DRAIN&VENT-WATER (EA.) ,00 �'
of not marc than five hundred dollars(my em:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
their sole compensation,will do the work,and the structure n not OCC.GROUP REB.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The C.mmemr's License Law does not apply to an owner of
properly who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 SO,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees.Provided that such improve- -
ments arc not intended his own
or ffered for employee,pr.If,ed that such
he building GAS-EA.SYSTEM-1 INCA OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM-OVER 4 (EA) 200
Dodder will have[he burden of proving flout he did not hufld o - . . .
r im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ 1,as owner of the property,am exclusively contracting with
and Pro contractorsCode
to construct the project La 7044,of apply LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and n owner of Code:The Contractor's License Low does not apply
to contracts
owner of properly who builds tr mor(e)ls thereon,and who LAWN SPRINKLERS-OVER 5IEA.) 1.00
the Contractor's
ons forsuch License
Lwith amntractorlxl licensed pursu:m[lo SEWER-SANITARY-STORM EA.200ft/10.00
the Contracloi s License Law. TRACT N0. PARCEL N0.
❑ I:vn exem of under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
\ Owner Date WATER SYSTEM 5.00 aCC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 �O
I hereby affirm that I have u pens tion In consent ms certified
or u certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
Pu1ic urc
z
"SnUll is hereby shede FIRE SPRINK ENERGY T-B<
z Z Hued copy is BICJ wi the city insp-ctimn Division.
MISC.- REFER TO ORD.
(] Ap IiCdnl V E] NE] I YE] NI
~ V3 ` HYD ' LPERMIT ISSUANCE 1"01 (N FLOOD ZONE A.L.U.C.
cc CFRT'IF-ICA" E 01'IiXEMI'TION PROM WORKS S'
W CObIPF.NSATION INSURANCE? PLG.CONED. LIC.rvO. PLG. 0..y
CL Z
(Phis section need not be completed if the permit is for one "t TOTAL v E] N V ❑ N
hundred dollars IS 100)or less.)
U 0 1 certify that in the performance of the work for which this per- CITY MECHANICAL PERMIT FEE .FEE SUMMARY
LL H mit is issued,I shall not employ any Person in:my manner so:u to
O W beconm subject to the Workers'Compensation Laws of California. '
Dace A licant BUILDING
a Pp ALTER OR ADD TO MECH. 5.00
} w NOTICE TO APPLICANT': If,after making this Certificate of Ex-
Z emption.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 sVvh.,aoviu.r,or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10/000C.F.M.) 4.00
CONSTRUCI'ION 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.C.L HEATING UNIT(TO 100,000 B.T.O.) 8.00 '
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the chose VENTILATION FAN (SINGLE) 4.00
S infornmlion is correct. I agree to comply with all city and tion,eounlY PLUMBING
ordinances and state laws relating to building construcand BOILER-COMPI3 H.P.or 100,000 B.T.U.1.6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCN. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,jud• if, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any a accrue agoi>rkt sai City in mnsequence of the
an a of is er it. MECH.CONT. LIC.NO. MECH.
o TOTAL TOTAL
ignalu p Ivan/C mraaor U
/ INSPECTOR COPY