8486 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
.-EIUI LDI NG PROJECT I DENT[FICATION PERMIT NUMBER
,ADDRESG�� 2�/ .�� APPLICATION & PERMIT
N� 2 BUILDING -ELECTRICAL-PLUMBING -MECHANICAL 8486
OWNER'S PLAN CHECK VALIDATION
Nr ME OTY. ELECTRIC PERMIT FEE
PHONE
CONTRACTOR UTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
CONTRA
ADDRESS
NTRA
PPLIANCES-RESIDENTIAL 4.00
/"fe PHONEfbglZ PANELS 10.00 I DATE OF APPLICATION /
OR
RLRITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
uc.NO SIGNS TRANS. 3.00
noon Ess ENc' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
APPLICANT s ZIP EMP.METER OR POLE INS. 20.00 If
ADDDRESSDRESSMOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
r o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a o U I hereby alhrm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. ECFA
ry i Professions Code,and my license is in full force and effect. El ElElz 0 w - License Class Lic.Number
o z r wo Date Contractor
¢r reBUILDING PERMIT
¢ ¢ w OWNER-BUILDER DECLARATION
E: 0 A MISC.- REFER TO OR INFORMATION
X 3 LL H 1 hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
H u o j Law for lire following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00
to Code:Any city or county which reyuiresa permit to construct,alter,
R ¢ Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR, LIC.NO. ELEC.
O u requires the applicant for such permit to file a signed statement that TOTAL ERMIT TO
d wCshe is licensed pursuant to the provisions of the Contractors License
FZi Law(Chapter 9(commencing wi th Sect ion 7000)of Division 3 o f t he
- a Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢ r o the basis for the alleged exemption.Any violation of Section 7031.5 1 STORIES TYPE CONSTR,
ate - by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 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,AR EA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.60 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself re through into his own employees.provided that such improve-
mess are throu hhis or offered employees,
or roe. ided that such
building GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, - . .) 2.00 the owner- GAS EASYSTEM-OVER 4 (EA
builder will have the burden of proving that he did not build or int- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ I,as owner of the property,am ex Clusively 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 contractorts)license.)pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ Iamexemptunder Sec. .B.&P.C.forthis WATER HEATER W/VENT 6.00
re.sm
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate of consent to self-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thercof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Certilied copy lshereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with the city inspection division. ❑
O Applicant MISC.- REFER TO ORD. v❑ N Y ❑ N❑
CC rO CERT117ICA1'E017 EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
Lu >_ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
f1 O Hhis section need not be completed if the permit is I'or one TOTAL YE] N❑ Y❑ N❑
Z hundred dollars(5100)or less.)
U O I certify that in the performance of the work for which this per- OT MECHANICAL PERMIT FEE FEE SUMMARY
IL 1- mit is issued,I shall not employ any person in any manner so as to
U.L be,... Object be Worke ompe'sal'On Laws of ahfornia.
U a 1� DamgZf�6ApPBca^t (`� IV£ ALTER OR ADD TO MECH. 5.00 BUILDING
} N
NOTICE TO AI'I'LICANT: If,afar making this Cert i(icate 7-Ex-
t ? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply will, FEE
U such provisions or this permit Shall be deemed revoked. AIR HANDLING UNIT(TO 10=QF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F. .) 6.00 SEISMIC FEE
I hereby affirm that there is a construction mit is
agency for EXHAUST HOOD(WITH DUCT)
the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T. .) 8.00 MICROFILM
3097,Civ.C.l.
Lender's H EATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's AddAJJrss ELECTRIC
I certify that I have read this application and Stale that the above VENTILATION FAN (SINGLE)
• information is Correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMPO H.P.or 100,0008.
hereby authorize representatives of this city
to
enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above mentioned properly for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.1
Cupertino against liabilities,judgments, costs and expenses which - CONST.TAX
may in any way accrue against Said City in consequence of the PERMIT ISSUANCE
gra 'ng Of this permit. MECH.CONT. LIC.NO. MECH.
-ZS-jI� Tor /0TOTAL
Signature of App nt/Con ac r ))arc
OFFICE COPY