8395 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
aUILDIN i9��S �', 2_r APPLICATION & PERMIT
y P BUILDING - ELECTRICAL-PLUMBING-MECHANICAL Q
L a_
O PLAN CHECK VALIDATION
•
ry NAME CITY. ELECTRIC PERMIT FEE p onE
NAMEA Rs OUTLETS-SWITCHES-RECEP 10:00/1.00
LIC,rvo LIGHTING FIXTURES 10.00/1.00
OONTRA T APPLIANCES-RESIDENTIAL 4.00
ADDRESS hw n0131-1 S414� p,(
_ dRSrvE PANELS 10.00 DATE OF APPLICATION
OR ec PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.No,
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRESS E SPECIAL CIRCUIT Zin •� 5.00 PERMIT VALIDATION
i zIPfrEMP.METER OR POLE INS. 20.00
ADDRESS C Y.6{'ltno MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 G
o o LICIiNSEU CONI'kAC'fOIiS D iCLARATIONV TEMP.POLE 30.00
a o v . I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
H G H (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F y z Protessions Code,and my license is in full force and effect ❑ ❑ ❑ ❑
ZOat - License Class Lic.Number y�
o ro Datc r- '3 -Comnnor
a x f BUILDING PERMIT
ar ¢ ¢ OWNER-BUILDER DECLARATION
a a u INFORMATION
wg ec m I hereby affirm that I am exempt from the Contractor's License IMISC.- REFER TO ORD
F u 0 4 Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
Code:Any city or county which requires a permit to construct,alter,
22 < 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
- 1 requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w m w he is licensed pursuant to the provisions of the Contractor's License
ri >
Law(Chupter9(commenciug with Section 7000)cf Division 3 oflhe
¢ Business coal Professions Code)or that he x exempt th..el,om and, CITY. PLUMBING PERMIT FEE 101/3 6--
Exa
¢ r $ the any
the afore ermit subjects
Any violation of Section 703L5 '�(i STORIES TYPE CONBTR,
di by any applicant fore porn sdjeds $5 applicant toacivil penalty ALTER-DRAIN -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
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
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 TOTAL ACREAGE
• himself re through tirate his own employers,provided that such improve-
memsarrhisnded ornemployeesale.rovided that such
building GAS-EA.SVSTEM-l1NC.40UTLETS 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 m[build or im- RES IND 'CNN PB OMer
prove 1'or purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 1.d as owner of the property,ton exclusively Se contracting with
lin,Pro contractors, construct for project La 7944,of apply
LAWN SPRINKLERS- 1 INC 5 V.B. 8.00 - ASSESSORS PARCEL NO.
and n owner of Codec The Contractor's License Law docs not apply -
co an owner of property aobuilds Ir improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projectss with
itlt a cntractorts)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the tam exempt
under
Sec, TRACT N0. .PARCEL NO.
❑ lam exempt 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.
WORKERS'COMPENSAT ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate i f consent to self-insure,
ora certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE N0.
copy thereof(Sec.3800,Lab.C.).
, ;X Policy No. Company Sr
Q ❑ Cerlil Sed copy is hereby furnis - FIRE SPRINK ENERGY M4
Z Z ❑ Certified copy is fled with the city inspection division. MISC. REFER TO ORD.
Off, Applicant Y N❑ V ❑ NE]
ti CIiR'FIrICATo Exl VMPFION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.c.
W > COMPENSATION INSURANCE PLG CONTR. LIC.NO. PLG. � N� Y � NF]
0 CI his section need not he completed if the permit is for one TOTAL aV
0
Z) 2 hundred dollar,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
D_ I- mil is issued,I shall not employ any person in any Incliner so as to
O W become subject to the Workers'Compensation Laws of California.
Q. Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} ro NOTICE TO APPLICANT: If,alter making this Certificate of Fs-
F ? eruption,you slmuld become subject to the Workers'Compensvtion APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be decried revoked. AIR HANDLING UNIT(TO 10000 C.F.M.) 4.00
CONSTRUCT 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 perfornnance of the work for which this permit is issued(Sec MICROFILM
3097,Civ.C1. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name - HEATING UNIT 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application andstate that the above VENTILATION FAN (SINGLE) 4.00
• information is correct.1 agree to comply with all city and county PLUMBING 0-0
oNinances and state laws relating to building construction, and BOILER-COMP(3H.P.or100,000B.T.U.) 6.00
hereby authorize representatives .1 (his city' I.e, en to upon the 60
R-COMP (Over 100,000 BTU)SEE FEESCH. 'MECHANICAL
above mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,Judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00 ,
MECH.
TOTAL TOTAL
gontingof this permit ,MECH.CONT. LIC.NO.
f/`
\� 6y{r1�(ufi'of"App rit nntractor Ualc �•
INSPECTOR COPY