C8655 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT 1DENTIFICATION PERMIT NUMBERBUILDING APPLICATION & PERMIT
ADDRESS
aDDnE55
4,10Z t214--S7&qj> BUILDING-ELECTRICAL-PLUMBING-MECHANICA0/ 8655
- I OWN PLAN CHECK VALIDATION
l� NAME OTY. ELECTRIC PERMIT FEE
vleAl nonE
NA'SOME OUTLETS
s UTLETS-SWITCHES-RECEP 10.00/1.00
t
uc.No. LIGHTING FIXTURES 10.00/1.00 '
DScroR's
ADDRESS PPLIANCES-RESIDENTIAL 4.00
AD
NE PANELS 10.00 DATE OF APPLICATION
DR HI ECT - T u ^S/F, PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER �J `I
LIC.No. 3 SIGNS TRANS. 3.00
ARM,OR i
ADDRESSE SPECIAL CIRCUIT -5.00 PERMIT VALIDATION
P qSa. EMP.METER'OR POLE INS. 20.00
ADDRESS +s` MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 �•)
°
0
� o o LICENSI:U CON I RACI)
'1'ORS 1!CLARA'1'ION TEMP.POLE 30.00
Fi w 1 hereby affno that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
a w (commencing with Section 7000)of Division 3 of the Business and
BLD ELECT. PLG. MECH.
D Z Professions Co rd y license is in full force un a fe t ❑ ❑ ❑
p0 In C scense Class _Lic.Number
m F Date Contractor 7no�+nr _
a x BUILDING PERMIT
IS ¢ wsc OWNER-BUILDER DECLARATION
a o a o INFORMATION
w g LL H I hereby affirm that I am exempt Gam the Contractor's License MISC.- REFER TO ORD
u 0 sr Law]or the following reason.(Sec.7031.5,Businessand Professions VALUATION g/FT.
� - Code:An cit or count which re<uiresa PERMIT ISSUANCE 10.00
Any y y 1 perntittots issuance,
also � - 000
SE IS Q improve,demolish,m repair any structure,prior to its iSauanCq also ELEC.CONTR. LIC.NO. ELEC.
O IS requires the applicant for such permit 10 file a signed Statement that TOTAL
n w m" he is licensed pursuant to the provisions of the Contractors License PERMIT TO
Hza Law(Chapter 9(commencingwith Section 7000)orDivision 3 ofthe rr
E i o Business and Professions Code)Or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
r m the basis for the alleged exemption.Any violation of5ection 7031.5 TORIES TYPE CONSTR.
i ; _ by any applicant for a permit subjects the applicant toacivil penalty
of not more than five hundred dollars(S500).): ALTER-DRAIN& VENT-WATER (EA.) 5.00
O I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 DCC.GROUP RES.UNITS
sole compenmtlnn,will do the work,and the structure n'nut
intended or offered for Sale(Sec. 7044, liusiness and Nofeseiotis 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 docs such work FIXTURES-PER TRAP 5.00 SO.FT FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsareGetintendedorofferedforsale.If.however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS EASYSTEM OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im- - . - .
BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 RES IND CON PB Omer
O I,as owner of the properly,are exclusively contracting with . .
❑ El El 1:1licensed contractor, to construct the project (Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 8.00 As5E5S0 ARCEL NO.
and I4ofessions Code. I'lie 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 acontractons)licensed pursuant to SEWER-SANITARY-STORM EA.200f1/10.00
the Contractors License Law. TRACT NO, PARCEL NO.
❑ lam 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.
WORK(?RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby aflinn that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE N0.
T
copy thereof(Sec 3800,Lab.CJ.
Policy No. Company -
O ❑ Cer6 dcopy is hereby ,, RT d' FIRE SPRINK ENERGY T-24
F O QQp.. Cetlified copy is fled with the city inspection division. MISC.- REFER TO ORD. y N y N
AITIIce ❑ ❑ ❑ ❑
OC �+ T"1'R IC 1 I- q'�' PERMIT ISSUANCE 10.00
Its' wiJ2$' FLOOD 20NE 'A.L.U.C.
W Cali I URANCIi PLG.CONTR. LIC.N0. PLG.
4' 0 (This section need not be completed it the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
LD Z hundred dollars(S 100)Dr less.I
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE _FEE SUMMARY
LL F- out is issued,1 shall not employ any person in any manner so as to
O W become subject to the Workeri Compensation Laws of California.
Date Applicam 'BUILDING
} 0 NOTICE TO APPLICANT: If,after making this Certificate of ES- ' ALTER OR ADD TO MECH. 5.00
F ? emption,you should become subject to the WorkersCompensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most lirthwith comply with FEE
CJ such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
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,Civ.C.). - HEATING UNIT(TO 100,000 B.T.U.) 8.00 !
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
ordinances n correct. 1 agree t0 comply with all city and cowry BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and ante laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100P00 BTU(SEE FEE SCH.
above-mentioned property for inspection purposes. MECHANICAL
01 agree to save, indemnify and keep hornless 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 accrue against said City in consequence of the
granting O(ihis permit. I MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
i8t ale
INSPECTOR COPY
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