8742 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BDILDING 110DO WMI :R ) r,$,i APPLICATION �^ ^
X, AOORESS 4I - ( G
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OwNER'a PLAN CHECK VALIDATION
NAME
I•
QTYELECTRIC PERMIT FEE
ONE
NAacroRs OUTLETS-SWITCHME ES-RECEP
10.00/1.00
LIGHTING FIXTURES 10.00/1.00 -
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
.�/ ADDRESS
HONE PANELS 10.00 DATE OF APPLICATION
A Cro I ECT PLAN CHECK FEE
ORy+ PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARC H.OR END, PERMIT VALI�TION
ADDRESS SPECIALCIRCUIT 5.00
ZIP 7EMP.METER OR POLE INS. 20.00 n,L7
APPLICANT
ADDRESS MOTORS SEE FEE SCH. JUC
SERVICE CHANGE 20.00 - 7 1985
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 Cl}}/ of C
¢ vw 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DAT/€e„/nO
w 3 e_ (commencing with Section 7000)of Division 3 of the Business and BL G. ELECT. PLG. MECH.
D z Professions Cod,,,and my license is in full force and effect. ❑ ❑
z o m,- Licensc Class_/) / Lia Number •-=T���
o L ° Dmc�_�tf�ts�_Contractor
a r E BUILDING PERMIT
¢ ¢ OWNER-BUILDER DECLARATION
a w u INFORMATION
w g LL w 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u0j Law for the following reason.(Ser,7031.5.Businessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
Code:Any city.,County which requires a permit to construct,alter,
¢ 2 a o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
iL O ¢ requires the applicant tie such permit to file a signed stu en eut'thal TOTAL
6 W m a- be is licensed parsuart to the provisions of the Contractor's License PER TiHO /�
z a
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
E O Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ a the basis for the alleged exemption.Any violation of Section 7031.5 S I PE'CONSTR.
u; r2 by anyapplicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of'not more than five hundred d.11urs($500).):
❑ I„as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 Oce.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,AR EA,CON D. 5.00 -
Code:The Contractor's License Lr W,I.es not apply to an owner of
property who builds or improves thereon,and who does si¢h work FIXTURES-PER TRAP5.00
• himself or through his own employees,provided that such improve-
mJ' so.Fr.FLDDR AREA ,,oT`L ACREAGE
ems are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-l 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 (EA) 200
builder will have the burden of proving that he did not huild or ice- GAS . - . .
- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 y❑ I❑ c F1Other❑
❑ 1,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 ASSESSO S ARCEL 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
contractsI.,such projects with a contractor(s)licensed pursuant to SEWER-SAN V-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO,
O I am exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 -
ACC.DATE ACC.FILE NO. / •
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a eerti0cate of consent to self-insure,
or a certificate of Workers'Compensation Insurunce,or a certified ZONING ENG,SITE NO.
x copy thereof(Sec.3800,Lab.CJ.
Policy No. Company
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z_ Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O , Applicant Y N� YE] N0
F wr PERMIT ISSUANCE 10.00
CC - Q>R'1'll'ICATIi OF F.XGSIPTION PROA1 WORKERS' FLOOD ZONE A.L.u.C.
-W D COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y N Y N ] '
0- 0 - (This section need not be Completed if the permit is for one TOTAL
V O hmrdord dollars($100)or less.)
I certify that in the performance of the work for which this per- FEE SUMMARY
LL I- mil is issued.I shall not employ any person in any manner so as to QTY. MECHANICAL PERMIT FEE
0 W become subject to the Workers'Compensation Laws of California.
o. Dat° -F-e-Appli°°"t ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOT ES O AI'I'LICAN'I': If, r nu mg Ili. ',,rt :x-
F 2 emption,you should become subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK -
provisions of the Libor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10SMCF.M.) 4.00
$ CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 t, SEISMIC FEE
I 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(Sec. MICROFILM
3097.Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lenders AddreHEATI NG UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
ss
1 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
•. ordinances and state laws relating to building construction. and BOILER-COUP(3 H.P.or 100,000 B.T.U.) 6.00
hereby uu litove relrresenwtoes it this city m emcr upon the BOILER-COMPlover 100,000 BTU)SEE FEE SCH. 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
granting of this permit. MECH.CONT. LIC.NO. MECH.
TOTAL \
\ .pp � b /-ar 6 f TOTAL
I\ W4. 5Appilicant/ o�t{trat� d- Uate
INSPECTOR COPY