8406 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS /�
C' BUILDING-ELECTRICAL-PLUMBING-MECHANICAL R
4N PLAN CH ECK VALI DATION
NAME OTY. ELECTRIC PERMIT FEE
urt A I PHONE
CONTRACTORS
NAME
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
tL L L LIC.NO. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00
ADDRESS. a Ip1(I
�� / pPIHONE (� PANELS 10.00 GATE OF APPLICAT ION
ARCHITECT PLAN CHECK FEE P.C.NO.
on JPANELS (OVER 200 AMIN 20.00
ENGINEER
LOC.No. SIGNS TRANS. 3.00
ADDDRESS ENGSPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
Ass
ADODRURErSS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 L
o w o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
G v
w I hereby affirm that I am licensed Under provisions of Chapter 9 ISSUANCE DATE
H rt (commencing with Section 7000)of Division 3 0l'the Business and BLDG. ELECT. PLG. MECH.
H w i Professions Code,and my license is in full force and effect ❑ ❑ ® ❑
O i m o Licenx Class Lin.Numbe
r w UatC . ! _Contractor
BUILDING PERMIT
¢ ¢o T OWNER-BUILDER DECLARATION INFORMATION
X
g LL_ I hereby affirm that I am exempt from the Contractors License MISC.- REFER TO ORD
u O j Law for the following reason.(Sec.7031.5,Businessand Professions VALUATION $/FT.
- N PERMIT ISSUANCE 10.00
m r Code:Any city or cuunty which requires permit to construct,alter,
Qor Q Q IDIprove,demolish,or repair any Structure',prior to Its issomaCe,also ELEC.CONTR. LIC.NO. ELEC.
¢ requires the applicant for Such permit to file U signed statement that TOTAL
a w m w h
e is licensed pursuant to Ore provisions of the Contractor's License PERMIT TO
F r
Law(Chapter 9(Commencingwith Section 7000)of Division 3 ofthe
i o Business and Professions fr
Code)or that he is exempt thereom and QTY- PLUMBING PERMIT FEE 701-WILY �6�
¢ H S the basis let the alleged exemption.Any violate...of Section 7031.5 STORIES TYPE CONSTR.
w. by any applicant for a permit subjects the applicant loo civil penally ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(SSOO).):
❑ I,as.wncr,of the property,or my employees with wages ax BACK F LOW PROTECT.DEV ICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work.and the structure is not
intended or,offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,GOND. 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 1 FIXTURES-PER TRAP 5.00 S0.FT.FLOOR AREA TOTALACREAGE
• himself or through his own employees,provided that such improve-
mind,
mProve-mints are not intended or offered for sale.If,however,the budding GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, - . - . .00 the owner. GAS EASYSTEM OVER 4 (EA ) 2
builder will have Ore burden of proving that he did not build or inn- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(See. 7044.Business LAWN SPRINKLERS-1 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 a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec...B.&P.C.for this WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5,611 ACC.DATE ACC.FILE NO.
WORKERS'COMPFNSAI ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby ateirm that I have a certificate.(consent or a Genion. ZONING
.r a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sec.3800,Lab,
policy No, Compn,ay
Q ❑ Certified Copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z I rtlfied copy is filed with the city inspection division. MISC.- REFER TO ORD.O AI ¢ant Y ❑ N❑ Y ❑ N❑
CC
CCr2 Clik'TIFICA O 017 EXEMPTION FROM W'ORAIiRS' PERMIT ISSUANCE 1_0,00
"� FLOOD ZONE A.LU.C.
W > COMPhiNSATION INSURANCE PLG.CONTR. LIC.NO, PLG.
CL 0 ('Phis section need not be completed if the permit is for one TOTAL Y❑ N❑ Y [3N❑
� Z hundred dollars IS too)nr less.)
L) O 1 certify that in lire performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY.
W U mil is issued,I shall not employ any person in any manner so as In
O w become subject to the Workers'Compensation Laws of California.
D. Date-Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} 0 NO'flCF '1'0 APPLICANT: IL after making this Certificate of Ex-
I- 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 101 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER I016.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work list which this permit is issued(Sec. MICROFILM
3097.Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING dt')
ordinances and state laws relating 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 tiro
above-mentioned property for inspection purposes. BOILER-COMP(Over 100,000 BTU)BEE FEE SCH. MECHANICAL
(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
Sirloin,of this permit MECH.CONT. LIC.NO. MECH. '
rX 0- 4 ,4* Q u J// J k t' TOTAL TOTAL
Sigloature of Applicant/Contractor Dior
INSPECTOR COPY