8750 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
APPLICATION & PERMIT
auILDlnc A 0
ADDRESS `}j(
BUILDING -ELECTRICAL-PLUMBING -MECHANICAL
O ER'B PLAN CHECK VALIDATION
"AME QTY. ELECTRIC PERMIT FEE
• fp,n - PHONE
ERAcroQs
N UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.ND. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR ADDRESS ons
PPLIANCES-RESIDENTIAL 4.00
4-42nPRONE PANELS 10.00 DATE OF APPLICATION
ACHtrecT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE v,c.No.
OR
ENGINEER
I.M.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
a o U I herchy affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y a c (commencing with Section 7000)of Division 3 of the Business antl BLDG. ELECT. PLG. MECH.
F D z professions Code and my license is in full fume and effect.
z ore - License CIL,Ccc '�--Lic.Number�D GR2�� El El9 m ° Write, 4/ .0;57 Contractor
¢ y f J BUILDING PERMIT
¢ as
OWNER-BUILDER UECLAkA'I'DON
LL o a" MISC.- REFER TO ORD INFORMATION
w g LL vP, 1 hereby affirm that 1 am exempt from the Contractor's License VALUATION
H LL o a Law for the following,eason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00
� m0 Code:Any city orcounty which requires a permit to construct,alter, ELEC.CONTR. LIC.NO.
IS ¢o improve,demolish,or repair any structure,prior to Its issuance,also ELEC.
y c u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License
rzr
Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe
i f�4u.v,&•vGr
¢ Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
f o
M f pm the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
Lo LLQ _ by any applicant for apennit subjects the applicant toacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred doll...($500)):
❑ I,as owner of the property,or my empluyecs 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 ar offered for sale(Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contract or's License Law docs net apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SO,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsannotintendedorofferedforsale,If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is Sold within one year of completion,the owner- GAS EASYSTEM OVER 4 IEA) 200
butitle,will have the burden of proving that h - . - . .
e did not build or int- BUILDING USE
prove for purpose ofsale). INDUSTRIAL WASTE INTER. 3000 REs IND CON PB Dater
.
❑ 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 ASSESSORS PARCEL NO.
and Professions Code:The Contracter's License Law does not apply
to an owner of property who builds of improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contrl cbrr(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ l mn 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'COMPENSATION DEC1,AkA'I'ION WATER TREATING EQUIP. - 5.00
I hereby affirm that I have a certificate of consent to sell-insure. ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sec 3800.Lab.CA
Policy No. Company /e
O ❑ Certified e'opy i. here fur !2 FIRE SPRINK ENERGY T 24
Z Z i7•.Cetl'Ged py I rvyth the city inspection division.
O Appl^e. �`�G. . MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N❑
~ ERPERMIT ISSUANCE dy FLOOD ZONE A.L.U.C.
LU y CERTIFICATE E EXITION INS PROM WORKERS'
W � COMPENSATION'INSURANCE PLG.CONTR. LIC.NO. PLG.
CLZ (Phis welled need not he completed if the permit is for one TOTAL Y❑ N❑ Y 1:1 NEI
hundred dollars f 5100)or sc..)U O 1 certify that in the performance of the work for which this per- OTY. ` MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued, I shall not employ any person in any manner so as to
O w become subject to the Workers'Compensation Laws of California. BUILDING
M Dote Applicant ALTER OR ADD TO MECH. 5.00
} to NO'I'ICl: TO APPLICANT:If,alter making this Certificate of Fe-
FZ emption,you should bacome subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions on this permit shall be dei nwd meokad. AIR HANDLING UNIT(TO 10)WOC.F.M.) 4.00
CONSTRUCTION LENDING AG ENCY 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
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 HEATING UNIT(OV ER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that 1 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 city to enter upon the BOILER-COMP 10var 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, oil anis, costs and expenses which CONST.TAX
may in any way .ecru La st said City in consequence of the PERMIT ISSUANCE 10.00
o
grunting is Penni A MECH.CONT. LIC.NO. - MECH.
TOTAL TOTAL
a,W ol'-Appll- t r • Uaw
INSPECTOR COPY