8558 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
aDORE55,
O /O - 1 BUILDING -ELECTRICAL-PLUMBING -MECHANICAL8558
/
'Claus'.' - PLAN CHECK VALIDATION
NAME
nqo/ _ L OTV. ELECTRIC PERMIT FEE
( l./IV PHONE U
NAMEC6NTRA ORs UTLETS-SWITCHES-RECEP 10.00/1.00 '
us LI
c.NO. GHTING FIXTURES 10.00/1.00
C-ONTRa ORS ss. APPLIANCES-RESIDENTIAL 4.00
ADDRESS '+.,k
PHONE PANELS 10.00 DATE OF APPLICATION
OARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE, P.C.NO.
ENGINEER
No, SIGNS TRANS. 3.00
ARCH.
ENG, PERMIT 5.00 PERMIT VALIDATION
Zlv TEMP.METER OR POLE INS. 20.00
ASS
ADDRESS MOTORS SEE FEE SCH.
DDREEA
SERVICECHANGE 20.00
° ¢ �r"'
'09 LICL'NSIiD CONTRACTORS DIiCLARATION TEMP.POLE 30.00
j
.Q v w I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
w a w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
y z Professions Code,and any license is in full force and effect
Q0 m o License Class Lie,Number
H w H Date _ Contractor
Contractor-
ac Y E BUILDING PERMIT
¢ ¢ ¢ OWNIIR-BUILDER DECLARATION
'o a INFORMATION
K
;u vHi I hereby affirm that I am exempt from the Contractor License MISC.- REFER TO ORD
.. o rt Law for the following reason.(Sec.7031.5,Business and Professions
VALUATION $/FT.
H _ PERMIT ISSUANCE ; 10.00
Code:Any city or county which structure perms incrustuanc alter,
¢¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. /7 ��
K D u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
n w m he is licensed pursuant to the provisions of the Contractor's License
i
Law(Chapter 9(commencing with Section 7000)of Division 3 offue
io Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEES 9k A
the basis 1'u1 the alleged exemption.Any violation of Section 7031.$ I STORIES TYPE CONSTR. `
u 3 _ by any applicant for a truant subjects the applicant to a civil penalty
Xof n t more than five hundred dollars(S500).): ALTER-DRAIN& VENT-WATER (EA.) 5.00
I,as owner ol'the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
t a' sole compensation,will do the work,and the structure is not
nteuded or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law docs not apply to an owner of
property who bullas m improves Thereon,and who does such work FIXTURES-PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such imp,o,r-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or Improvement is sold within one year of completion, the owner- GAS EASYSTEM OVER 4 IEA) 200 BUILDING USE
builder will have the burden of proving that h - . - . .
e did not build of int- RES IryCON PB Other
m
Prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 13 El El El 1:1❑ 1,as owner of the property,aexclusively contracting with
. licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-I 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 for such projects with n contractods)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ I um exempt under Set. ,B.&I'.C.for this WATER HEATER W/VENT 6.00
0
Owner i Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORRERS'COMPENSATION DECLARATION . WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insura. ZONING ENG.SITE NO.
Or a certificate of Workers'Compensation Insurance.or a certified
fcopy thereof(Sec.3800,Lab.C.). '
Policy No. Company I
❑ Cerlified ropy is hereby furnished. FIRE SPRINKENERGY T-24
El '
z Z Certified copy is Filed with MISC. REFER TO ORD.the city inspection division. -
O Applicant y E] NE] y E] N[3
F" rn PERMIT ISSUANCE 10.00
LU > CIiRTIFICCCMPF EXEMPTION PROMW'ORRIiRS' FLOOD ZONE A.L.uC.
W � COh1PIiNSATION INSURANCE. PLG.CONTR. LIC.N0. PLG.
CL O This section need not be completed if the Permit is for one TOTAL Y❑ N❑ Y ❑ N❑
::I Z hundred dollars IS 100)or less.)
9 1 certify that in the performance of the work lou which this per- OTV. MECHANICAL PERMIT FEE FEE SUMMARY
•L.L U mil is issued,I shall not croploy any person in any manner so as to
O ID become subject 1 the Workers'Com enrol on Laws of California.
A Dmc A he°m `�`/T-'- ALTER OR ADD TO MECH. 5.00 BUILDING 9
} to No FIC1` O APPLICAN'1: If,!1'tcr maB t tis Ccrti hen of li x- �l --
F Z ¢option,you should become subject to the Workeri Cmrmr alum APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you muss forthwith cooply with FEE
U such provisions or this permit shall be deemed(evoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCT ION LP-NDINO AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
1 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(See MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
eam
Lender's N
LeHEATING UNIT 100,000 B.T.U.)9.50
Lenders Nam e- ELECTRIC
I certify that 1 have read this application and state that the abuse VENTILATION FAN (SINGLE) 4.00
• information is correct. I agree to comply will,all city and county PLUMBING
ordinances and state laws relaling 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 BOILER-COMP (Over 100.000 BTU)SEE FEE SCH.
above-mentioned properly for inspection purpons. 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 10,001CONST.TAX
may in any way accrue against Said City in consequence of the
granting of ,is permit, MECH.CONT. - LIC.NO. MECH.
_ TOTAL TOTAL 3Uov
Sififflutbryof Applicant/Contractor Dule '
INSPECTOR COPY