8572 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT lDENTIFICATION PERMIT NUMBER
NG APPLICATION & PERMIT
ADDRESS ADDRRESSSS
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL8572
OWNER'S PLAN CHECK VALIDATION
"AME OTY. ELECTRIC PERMIT FEE
PHONE G Z
CONTRACTOR
NA
NAME I � OUTLETS-SWITCHES-RECEP 10.00/1.00
f� ua No. LIGHTING FIXTURES 10.00/1.00
ADORESCT PPLIANCES-RESIDENTIAL 4.00
ADDRESS
'1
<7FHONE ;2:�Q�C172 PANELS 10.00 DATE OF APPLICATION
oqc"ITL-7:7 - PANELS 200 AMP) 20.00 PLAN CHECK FEE PG.No.
E NOINEER
uc.NO SIGNS TRANS. 3,00
AARCH,OR
DDRESS ENG. SPECIALCIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 �f
ADDAESSPLICANMOTORS SEE FEE SCH. /,(/`
,.DUREss /
SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a v 1 hereby ufl'irm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and
a a BLDG. ELECT. PLG. MECH.
H w w Professions Code,and my license is in full fora and effect.
i2a License Clnss' '�i Lic.I<umhcr ♦Q
F m r j DatC�.,_J�� Contractor r
El El El
A ac f BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DECLARATION
a od u INFORMATION
w3 LL N 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
u O j Law for the following reason.(Sec.7031.5,Business and Professions VALUATION $/FT.
� - 'Code:An cit or county which reuiresa PERMIT ISSUANCE 10.00
Any y y permit to construct.
¢ ¢ c p mr r
improve,deolish,oepair any structure,prim issuance.a
to its issuncelso ELEC.CONTR. LIC.NO. ELEC.
E. O
a-
requires the applicant for such permit to file a Signed Stalelrtera that TOTAL PERMIT TO
a ce m he is licensed pursuant to the provisions of the Contractor's License
F z i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
ExD
¢ 3:o the basis for the alleged exemption.Any violation of Section malty STORIES TYPE CONSTR.
am
d -. by any applicant fora permit subjects tire applicant toa civil penalty ALTER-DRAIN -WATER (EA.) 5.00 1
of not more than five hundred dollars(5500).1',
❑ I,as owner of the property,Dgmy employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole Compensation,will do the work,and the 5l ruclurc is not
intended or offered for sale (Sec. 7044, Business and profession DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:'I'hc Contractors License Law does on apply to am owner of
properly who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SO,PT.FLOOR AREA TOTAL ACREAGE
IIII11SCII or through his own employees,provided that such intprove-
melsarenotintendedorOffered for sale.if however,lire building GAS-EA.SVSTEM-11NC.40UTLET6 6.00
i or improvement is sold within one year of completion, the owner- GAS EASYSTEM OVER 4 (EA) 200 BUILDING USE
builder will have the burden of proving that he did not build or im - . - . .
RES IND CON PB Ober
for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 1,as owner of The property.am exclusively contracting with El ❑ ❑ El Q
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 forsuch projecowith a conlractorls)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec.—,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM - 5.00 ACC.DATE ACC.FILE NO.
( WORKERS'COMPEN'SATION DECLARA'IION WATER TREATING EQUIP. 5.00
i 1 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 Omrcof(See 3800,Lab.C.).
Policy ND(,.} Coipany �� 1!(tE(Z r2Qt y�
O 0 Cerrfed mpy'is hereby furnished. FIRESPRINK ENERGVh]4
z Z C* Certified ropy is fled itll the city inspection division.
A MISC.- REFER TO ORD.
O Applicant_,�_rf—l�'r(L V [:] N� V � N�
ir w n CIERTIFICATEOF EXEMPTION FROMWORKIERS• PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.UL.
LU COMPENSATION INSURANCE PLG.CONTE. LIC NO. PLG. Y� NEI Y � NEI
CL Z (' Phis section need not be completed if the permit is for one TOTAL
hundred dollars($100)or less.)
U O I certify that in the performance of the work for which this per GTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I— mit is issued, I shall not employ any person in:my manner so as to
U become subject to the Workers'Compensation Laws of California-
U y Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE:TO APPLICANT: If,after making this Certificate of Ex-
Z eruption,you should become subject to the Workers'Canpensatiou APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith Comply with FEES
U such provisions or this permit shall be J,Cowd revoked. AIR HANDLI G UNIT(Td 1Q000OF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MIC.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH (DUCT) 5.00 F.—
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 4c,Lender's Name H EATI NG UNIT(OVER 100,000 B.T.U.M.-SO
Lender i Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COfv1P(3 H.P.Or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100.000 BTU)SEE FEE SCH. W MECHANICAL
above-mentioned property for inspection purposes.
(WC) agree to save, indemnify and keep Imreless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgntenls, costs and expenses whichpERM1T ISSUANCE 10.00 _ CONST.TAX
emy in any way accrue against said City in consequence of the
grantin of Ibis pcnni MECH.CONT, LIG NO. MECH.
/� co
TOTAL TOTAL
ShEnatur, n our Uate A
INSPECTOR COPV
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