C8733 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
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BUILDING PROJECT IDENTIFICATION \ PERMIT NUMBER
aDILDiNG APPLICATION & PERMIT
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL ) E733
OWNER'Si LAN CHECK VALIDATION
A NAME d SY.-/3G $" QTY. ELECTRIC PERMIT FEE ( _/
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00 J
Lie NO. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.NO. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIALCIRCUIT ,5.00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT'5 MOTORS SEE FEE SCH.
ADDRESS ((I /
SERVICE CHANGE 20.00 ((
o o LICENSED CONTRACTORS DECLARATION TEMP. POLE 30.00
w
a v uI hereby affirm that 1 em licensed under provisions of Chapter 9 y10 ISSUANCE DATE n
m G a (comnlusmg with Section 7000)of Division 3 of the Business and BLDG ELECT. I PLG. LMEGH.
F w z Professions Code,and my license is in full force and effect a a El ❑
z o ce License Class m
Lie.Nuher Is,
o Z F o Date Contractor
a y E 1 IN PERMIT
M SE re ¢ OWNER-BUILDER DECLARATION INFORMATION
aoo_ " MISC.- REFER TO ORD
w 3 J. I hereby affirm i hal I so exempt from the Contractor's License VALUATION SI/FT.
HLLoJ Law for the following reason.(Sec.]031.5,Businatiand Professions PERMIT ISSUANCE 10.00 •'"J�
Code'.Any city or county which requires a wrmit to construct,alter,ce
S� i
W ¢ 2O improve,demolish,orrepair 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' PERMITTO
w m he is licensed pursuant to the provisions of the Contractors License
H or es Law(Chapter 9(commencing with Section 70000of Division 3 of the
- a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
T'o
H o the basis for the alleged excm ption>Any violation of oecnon k STORIES TYPE DNSTR.
ate _ by any applicant fora purnlit subjects the applicantttOacivil penalty malty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(8500).:
❑ I,as owner of the property,or my employees with wages as BACKFLOW PROTECT. DEV ICE 4.00 Dcc.GROUP RES.UNITS
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,COND. 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 FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself to through his own cared fors provided that such improve- .
meNsare tot hroughh is ore employees,
provided
that s thebtilding GAS-EA.SVSTEM-11NC.40UTLETS 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 he did not build or im-
proveforpurposeofsale.. INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB ower
D I,as owner of the property,am exclusively Contracting with '❑ ❑ M ❑ ❑
licensed contraetorc to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSO RCELNO.
and Professions Code:The Contractor'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 contractors)licensed pursued to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
,� rc❑ lam exempt under Sea ,B.&P.0-for this WATEWHEATE,R W/VENT 6.00
/ Owner Date< WATER SYSTEM 5.00 ACC.OATE ACC.PILE NO.
W'ORKERS'COMPF-NSATION DECLARATION WATER TREATING EQUIP. 5.00 '
I hereby affirm that I have a certificate of crosonI tO wIl insure,
or a certificate of Workers'Compensation Insurance,or a Certified ZONING ENO.SITE NO.
copy thereof(Sec.3800.LaoC..
Policy No. Company
0 ❑ Certified copy is hereby furnished. j FIRE SPRINK ENERGY T 24
Z Z ❑ CeHgn,c1 copy is filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant 'y.❑ N❑ Y E:] N❑
L- M'y CERTIFICATE OF EXEMPITON FROM WORKERS' PERMIT ISSUANCE rF� 10.00 FLOODZONE A.LU.C.
W COMPENSATION INSURANCE PLG.CONTR. LIC.NO. ly<f .PLG. 1
('Chis section need not be completed i1the permit is for one TOTAL Y❑ N❑ Y❑ N❑
hundred dollars(5100)or less.
U 0 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
EL F mit is issued,1 shall not employ any person in any runner so as to
U become subject to tire Workers Compensation Laws of California.
0 Ed Date Apph°ant ALTER OR ADD TO MECH. 5.00 BUILDING S�
} to NOTICE TO APPLICANT: If,utter making this Certificate of Ex-
F. ? 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 snob provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO JOSMC.F.M.) 4.00
CONSTRUCTION LENDINCACENCY AIR HANDLING UNIT(OVER IOSMC.EM.) 6.00 SEISMIC FEE SO
1 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, HEATING UNIT(TO 100,000 B.T.U.) 8.00
Leader's Narric HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I Certify that I Imre read this application and stale that"It above V ENTILATION FAN (SINGLE) 4.00
info nn anon is correct 1 agree to c'onuply with all city and County PLUMBING
ordinances and state laws relating to building eonstruenon, and BOILER-COMP(3 H.P.or 100,0006.T.U.) 6.00
hereby authorize representatives of this city to enter upon tllL BOILER-COMP (Over 100,000BTU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agmc to one, indemnify end keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way acerae against said City in consequence of the PERMIT ISSUANCE 10.00
gran/ting of this permit. / MECH.CONT. LIC.NO. MECH.
"
40 �G_ )- 7 TOTAL TOTAL
aturc o1 A plicent/C�i'�$� �-17n1e
INSPECTOR COPY
I