8404 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICA �•� PERMIT NUMBER
Hot LDING APAAAPPL'ICA ION & PEFO - e n
ADDRESS / /� (�
ILDI G-ELECTR CAL-PLUMBING -MECHANICAL
PLAN CHECK VALIDATION
NAME
4 OTY. ELECTRIC PERMIT FEE f,
t vnoNE L 30
NAME is OUTLETS-SWITCHES-RECEP MOO11.00 F,,2 4_-
LIGHTING
LIGHTING FIXTURES 10.00/1.00
(,S (019 APPLIANCES 4.00
nooREss
SC
. JCI ONEL t Q PANELS IO W GATE OF APPLICATION
'- oHT r PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
n
'N "EER
Lt..NOC SIGNS TRANS. 3.00
ADDra RESS E a. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
.• _ Zlv I EMP.METER OR POLE INS. 10.00 _
ADDRESSTs MOTORS SEE FEE SCH. fes_
H
Vxe C t f SERVICE CHANGE 20.00
a o LICENSED CONTRACTORS DECLARATION TEMP.POLE ,30.00 W/ (Ja//
Vle•/
,(
< i I hereby affirm that I um licensed under provisions of Chapter 9 ISSUANCE DATE
y (conuncncing with SFction 7000)u(IJivisiwl 3 critic Business and
Q y BLD ELECT. PLG. MECH.
D z Professions Code,a y license is in full force anslyffpct
o i m o License Class Lic.Nmnbcr {
Date Contmet or t
BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DECLARATION
¢ u, INFORMATION
v'x ;A w 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
.. o G Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCEVALUATION 5/FT.
� -0 Code:Any city orcouniv which requires a permit to construct,alter,
¢ m Y ELEC.CONTE. LIC.NO.
ce ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.
O u requires the applicant for such permit to file a signed statement that TOTAL 1j PERMIT TO
A w m
i he is licensed pursuant to the provisions of the Contractor's License
r z
Law(Chapter 9(commencing with Section 7000)of Division 3 offlue VVIV
< Business and Professions Code)or that hQTY. PLUMBING is exempt therefrom and QTYPLUMBING PERMIT FEE
¢ Fo the basis for thealleged exemption.Any violation of Section7031.5 STORIES TYPE CONSTR.
A•� .- 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 doll...(8500).1'.
❑ I,as owner of the property,or my employees with wase.as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the Structure is not "'OCC.GGROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 r// /
Code:"I'he Contractor's License Law does not apply to an owner of !!fill......
property who builds or improves thereon,and who doe's such work FIXTURES-PER TRAP 5 'art.
himself or through his own employees,provided that such improve- 4' SD.FT.FLOOR AREA .TOT L ACREAGE
ments are not intended or offered for Sale.I L however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS A= ,u
62
or improvement is said within one year of completion,the owner- GAS-EASYSTEM-OVER 4 (EA.) 200 wL ING USE
builder will have the burden of proving that h . . .
e did not build or im- RES IND CON PB OrM1er
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00
❑ 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 ASSESSORSPARCEL NO.
and Professions Code:The ContmctoYs 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 fur such projects with it convautoos)licensed pursuant to SEWER-SANITARY-STORM EA,200ft/
♦ the CmdmCtat's License Law. LOM "f� TRACT NO, PARCEL NO.
L ❑ I runexempt under Se,. ,B.&P.C.for this WATERHEATER W/VENT 6.00 Oo
talon k
Owner Date WATER SYSTEM 5.00
ACC.DATE ACO.FILPNO.
y, WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00 at
,., I hereby affirm that 1 have a certificate of convent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
Copy thereof(See 38Co,Lab.c.).l`raF lS-�
Policy er f Company �1
O ❑ CeRiticd copy is hereby fi hed. FIRE SPRINK ENERGY T-24
Z Z eat ifiwd copy is filed with the city inspection division.
O Ap cant MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N❑
lr ti CERI'IFICATE OF EXEMPTION PROM WORKERS' PERMIT ISSUANCE r d'V FLOOD ZONE A.L.U,C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
* 0- Z Hhis section need not be completed if the permit is for one TOTAL �'� Y El NE Y El ❑
N
hundred donors is 100)or Iess.)
U O I certily that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any Tanner so as to
U hecone subject to the Workers Compensm ion Laws of California.
a Dam ApplicantBUILDING �•' )
} m NOTICE 'f0 APPLICANT: If,after making this Certificate of Ex- ALTii ER bR ADD TO MECH. 5.00
Z_ emplion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
I 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=11F.NL) 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
-I'hereby.affirm that there is a construction leading agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
o
3097-C C) HEATING UNIT(TO 100,000 B.T.U.) 8.00 !/L
Lender's Name ��.` 'P'x/'). Y�- N,
Lender's AJdre 11� tr�E+{- 'j}- HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
.1 i cerfily that l have read this ppl"linand stat that the above r` VENTILATION FAN (SINGLE) 4.00 4�
1 tt tie is correct I agree to comply with all city and county - PLUMBING
ordinances and state laws r lalmb to hlllding constructlon..and BOILER-COMPO H.P.or 100,6008.T.U.) 6.00
hereby authorizerepresentatives of this city t enter upon tie BOILER-COMP (Over 100.000 BTU)SEE FEE SCH
above nuntioned property for inspection purposes. . MECHANICAL
(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 f/L CONST.TAX
may in any way accrue against said City in consequence of the /
grantingof this perrpil MECH.CONT. LIC.NO. MECH.
0 I TOTAL TOTAL 0,36 7 /�
l S cotApplicant/Con tractor Uate Z
INSPECTOR COPY