8164 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDINGAPPLICATION & PERMIT r
ADDRESS I. I ' l r
WO-6
UILDING-ELECTRICAL-PLUMBING -MECHANICAL .$16
W RY - PLAN CHECK VALIDATION
• ME QTY. ELECTRIC PERMIT FEE
q �S
CONM CroR's OUTLETS-SWITCHES-RECEP 10.00I1.00
LIC.NO. LIGHTING FIXTURES 10.00/1.00 '
r- TRACT �{ctQ- APPLIANCES-RESIDENTIAL 4.00
A RESS irr+-O
\. PRONE PANELS 10.00 DATE OR APPLICATION
DR IT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER _
uc.NO. SIGNS TRANS. 3.00 s
AARCH.OR DDRESS ENr�. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
p EMP.METER OR POLE INS. 20.00
AICEArs
ADDRESS MOTORS SEE FEE SCH. C
DDRJ
SERVICE CHANGE 20.00 a
0 0 0 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 3//
a mo U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w "' (commencing wt Sec- n 70001 of Division 3 of the Business and
a w BLDG. ELECT, PLG. MECH.,
D z Professions C a , license is in full for' a ect
z o v, - License ass Lie.Nwnbe El � ❑
4 m H �w Dat Contractor
a a 1 BUILDING PERMIT
a a a iR.BU1LDER DECLA ATI
o a U INFORMATION
w ;LL 1 hereby affirm that I am exempt from the Contractor's License MISC.- _ REFER TO ORD
LL04 law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10,00 VALUATION $/FT.
� - 0 ade:Any cit y orcou n l Y which req ui res a permi t to construct,a l t eq
or to its issuance,also ELEC.CONTR. LIC.N0.
¢ a O innpnrv4 demolish,or repair atny structure,P^ ELEC.
D u requires the applicant for such fiction to file a signed statement that TOTAL PERMIT TO
K
m he is licensed pursuant to the provisions of the Contractor's License
H z a Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe ti/L ,
f 4 o Business and Professions Code)or that 1¢is exempt therefrom and QTY. PLUMBING PERMIT FEE L�
¢ I- the basis for the alleged exemption.Any violation of5ection 7031.5 STORIES TYPE NSTR,
n3 by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN IEA.) 5.00
of not more than five hundred dollars(S500).):
0 I,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 4.00 •O c.G OUP REB.UNITS
their sole compensation,will do the work,and the structure Is not
intended or offered for sale (Sec 7044, Business and Profcsxions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:'I'Ie Contractor's License Law does not apply to au 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 or through his own employees,provided that such. improve...lents arc not intended noffered for sale.If.however.the huilding GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00 11
or improvement is sold within one year of completion,thr e owner. GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or int- BUILDING USE
prove for purpose ofsaleJ' INDUSTRIAL WASTE INTER3000 RES IND CON PB Other
❑ I,as owner of the property,am ext'In . .
slvelY contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 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 contmctoos)licensed Pursumu to gEWER-SANITAR V-STORM EA.200f1/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
' ❑ I am exempt under Sec. ,H.&PC.Inr this
reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
•;� WORT:ERS'COMPI:NSA'IION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a cerci cats of consent to self-ivu re. ZONING ENG.SITE NO.
or a certificate of Workers'Corepen tion Insue rancor a certifieJ
copy thereof(Sec.3800,Lab.C.1
V Policy o. Company
O Certified copy is h eby furnish tj 1�///
Z Z ertfffed c y tiled wilh'fie I tt IIOR r n. FIRE BPR INK ENERGY T24
MISC.- REFER TO ORD.
D• Applicant y❑ ry❑ y ❑ N❑
Fy`( I PERMIT ISSUANCE 10.00 PLo°D zoNE A.L.uc.
f,ERTI FI AT OF IS%Eh1P )Iyi f' M1 WOR?i' V,W > C IPENSAT'10 IN RAN ° PLG.CONTR. LIC.NO. PLG.CL O 1'Ihis section need not he cmmdemA if the Pen is fne TOTAL Y❑ N❑ Y ❑ N❑
:3 Z hundred dollms($100)or lcss.l
U O I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE - FEE SUMMARY
LL {- mit is issued,I shall not employ any person in any manner so as to
O w become subject to the Workers Compensation Laws of California. p
y Datc Applicant ALTER OR ADD TO MECH. 5.00 BUILDING �J
} to NOTICE TO APPLICANT: If,after making this Certificate of Es-
F ? emption,you should become subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK ) cAles
-
provisions of the Labor Code, you must forthwith comply with FEE o(O
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 7�•0
I hereby affirm that there is u construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the lerrlor97, munce of the work for whi,kh this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's
Address
Name
LAddreHEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's ss ELECTRIC
I certify that I have read this application and nate that the above VENTILATION FAN (SINGLE) 4.00
information is correct.I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction. and BOILER-COMP(3 H.P.or 100,000 B.T.U:1 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,0008TW SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
Ove) age e to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino am Iminfl fes, 'udgments, cos s and expo xes which PERMIT ISSUANCE 10.00 CONST.TAX
1)7
InnY I waY a c u Inst said City n conscyu me of the
gra i Ithis' rn't. / ECHla4 .CONT. LIC.NO. MECH. _
TOTAL TOTAL 7a �s
plf a t/C fA DWI
INSPECTOR COPY