8217 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
r
ADDRESS
• �' �' - ly ^ • BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 8
OWNER'S / PLAN CHECK VALIDATION
\'"AME / (/n OTV. ELECTRIC PERMIT FEE
• / 4 L• /,dC• 7 -PRONE Y
CONTRACTOR'5
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
LIE No. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
oP '4 PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARC H.OR ENG. PERMIT VALIDATION
ADDRESS SPECIALCIRCUIT 5.00
ZIP EMP.METER OR POLE INS. 20.00
ADDRESS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
D a z MP.POLE 30.00
Foo s LICENSED CONE RACI'ORS UDECLARATIONT E
Mo u I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
¢
z w (commencing with Sermon]0001 of Division 3 of the Business and
¢a BLD ELECT. PLG. MECH.
F m i Professions Code,and my license is in full force and effect. ❑ ❑
Z o w - License Class Lie.Number
o m r w Uatc Contractor
BUILDING PERMIT
E 0 n O OWNER-BUILDER DECLARATION INFORMATION
w g I- 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
of VALUATION $/FT.
r LL 0 sc Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
my CodC Any city or county which rttpliresa permilloconstmcLale"
¢ ¢ improve,demolish,or repair any structure,p ,prior to its nsomee also ELEC.CONTE. LIC.NO. ELEC. /
i o u requires the applicant for such permit to file a signed statement that TOTAL
w m he is licensed pursuant to the provisions ofthe Contractor's License 1 PERMtT-TO
FZQ
Law(Chapter9(commencing with Section 7000)of Division 3 of the
F i o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE ,
a r m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES 7YIE CONSTR.
to
ate _ by any applicant for a permit subjects the applicant o a civil penalty ALTER-DRAIN -WATER IEA.( 5.00
of not more than five hundred dollar,(5500)J:
❑ I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 oec:GROUP RES.UNITS
their sole compensation,will do lite 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 docs such work F IXTUR ES-PER TRAP 5.00 So,FT.FLOOR AREA TOTAL ACREAGE
himself re through ot de own employees,for
sole.
provided that such improve
mmselfe throuhh is or offered Sa le.Iided that suhcbulldle GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
W."
r will have the burden of proving that he did not hulld or im- BUILDING USE
for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 REs IND CON PR omer
Lasownerof the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑d contractors la construct the project(Sec 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
ofessions 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 IEA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA:200ft/10.00
lite Contractors License Law. TRACT NO. PARCEL NO.
re❑nlarri urptu er SBAP.C.For this WATER HEATER'W/VENT 6.00
WATER SYSTEM 5.00
JI ACC.DATE ACC.FILE NO.
WORKERS'COMPENSA1'ION DECLARATION WATER TREATING EQUIP, /r 5.00
I hereby uffinr that I have a certificate of ains'ent In salGin,ar, ! ZONING
or a certificate of Workers'Compensnion Insurance,or a certified \ ENG.SITE NO.
copy thereof(Sec.3800,Lob.C.).Policy Nn. Company
' O O 'Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z ZO Applicant(3 Certified
iced copy is filed with the city inspection division. MISC. REFER TO ORD. Y
❑ N❑ Y ❑ N❑
. CCN CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
IL > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
Z) Z hundred dollars IS 100)or less.)
f) O 1 cerlily that in the perforurinee of lite work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,1 shall not employ any person in any manner u'as to
become subject to the Wnrkcrs'Compmhsmion Laws of California.
d
DateAppli°antALTER OR ADD TO MECH. 5.00 BUILDING
} m NOTICE TO APPLICANT: If,after making this Ce,rfecyte of Ex-
F 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 such provisions or this permit shall be deemed revoked. 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 v
1 hereby affirm that Imre is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the 3097performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Larder's Name
Lender's NameAddress HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
infornhation is correct. 1 agree to comply with all city and coumy PLUMBING
ordinances and stale laws relating to building construction, and BOILER-COMP(3H.P.or100,000B.T.U,) 6.00
hereby authorize representatives of this city to en ler upon the
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 tTD)SEE FEE SCH. MECHANICAL
(We) agree to Save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against Ii bilines,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
ma Tri any way ccrue against Said City in consequence of the
By t(pg of this p���it.OO__'' � ECH.CONT. LIC.NO. MECH.
/Sg /1 Pl�l/Y/G�1/ TOTAL TOTAL
VSignature if, pplic nl/Contractor Date
INSPECTOR COPY
I