C8706 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
STILDING APPLICATION & PERMIT O
� ADDRESS OREss
i BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIOATION
\� NAME ' CITY. ELECTRIC PERMIT FEE y'.
i PHONE G1�
CONTRACTORs UTLETS-SWITCHES-RECEP 10.00/1.00
NAE-
sec.No. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR,
ADDRESS PPLIANCES-RESIDENTIAL 4.00
• 1. NE PANELS 10.00 DATE OF APPLICATION
TRC ECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
sec.No. SIGNS TRANS. 3.00
AARCH,OR DDRESS ENG. SPECIALCIRCUIT 5.00 PERMIT VALIDATION ,
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH. �( '
ADDRESS ( _
SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 ����S
F u w 1 hereby'affirm that I am licensed under provisions mfChapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG., MECH.
H N Q Professions Code, d m license is in full force and a feet A + ❑ ❑ ❑ ❑
z o m ;Z\ License Class ¢ Lic.Number I
Date___S�_• / Contmcwr
ZZ
m a 1 BUILDING PERMIT
rc p w a OWNER-BUILDER UECL T'N O INFORMATION
A 0a- MISC.- REFER TO ORD
.w 3 LL I hereby affirm that I am exempt (roto the Contractor's License VALUATION $/FT.
-F c 0 a Law for the following reason.(Sec.7031.5,Business and Professions PERMITISSUANCE 10.00
Code:Any city orcounty which requires a permit to construct,alter // 000
QQ Q Q Improve,demolish,or repair any Structure,prior to Its Issuance,also ELEG CONTR. LIG NO. ELEG • /
ce
O¢ requires the applicant for such permit to file a signed Statement that TOTAL PERMIT TO
d w.m" Ire is licensed pursuant to the provisions of the Contractor's License [h�
z Law(Chapter 9(commencing with Section 7000)of Division 3 of the
a �D
Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
IS the basis for the alleged exemption.Any violation ofSection 7031.5 STORIES TYPE CONSTR.
m by any applicant for a permit subjects the applicant toa civil penaltyw
of not more than five hundred dollars(S500).) ALTER-DRAIN&VENT-WATER (EA.)L5.00 -..
❑ I,as owner of the property,or my employees with wages as -BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an..our of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.PT.FLOORAREA TOTALACREAGE
• himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I1NC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving that Ito did not build or im
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ I,as owner of the property,ant exclusively con(mding with ❑ ❑ ❑ ❑ ❑"
licensed contractors to construct.(he'project(Sec 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Cootramor's License Law does not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contr9ctor(s)licensed pursuant no SEWER-SANITARY-STORM EA'.200ft/10.00 ,t
the Contractors License Law. TRACT NO. PARCEL NO.
❑ lmor.roptunder Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACGDATE ACC.FILE NO.
WORKS RS'COMPINSATION DECLARATION WATER TREATING EQUIP. �• _ „5:00 y
I hereby affirm that I have acerti0cateofconsenl IOSelf-insure, ,
or a certificate of Workers ZONING Compensation Insurance,or a certified ENG.SITE NO
copy thereof(Sec.3800,Lab.CJ. ( /0
Policy Nn. (y�,• J117TMlpany !
O ❑ Curti," ed npy is hereby I orneshecF.7D P FIRE SPRINK ENERGY T-24
z'2 AO�Certified 'opy..is Hr uh city pa o division.
FO r�fi�lIcant ii -r- MISC.- REFER TO ORD. Y ❑ NE] YE] NE]
CCN CERTIFICATE 01'EXEMPTION FRO,kj WORT wrp-i PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU > CO.11PENSATION INSURANCE PLG.CONTH. LIC.NO. PLG.
d Y❑ N❑ V❑ IN[]
(This section need not be completed if the permit is for one TOTAL
Z) Z hundred dollar,IS 100)or IeuJ
L) O 1 ccrtil'y that in the purforomncc of the work I'..which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,1 shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws o(California.
O w Date-Applicant BUILDING
D. ALTER OR ADD TO MECH. 5.00
} to NOTICE 1'0 APPLICANT: If,after making this Certificate of Ex.
? 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
such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE -77
1 hereby affirm that there is a construction lending agency I'or EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
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
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 cityto enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property'for inspection Purim S.
(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 CONST.TAX
may in any way ace see against said City in consequence of bin
';mling -tI
'ofMECH.CONT. LIC.NO, MECH.
S to-T-
INSPECTOR
TOTAL 7 a
ngnat 1 /Contractor Date
INSPECTOR COPY