C8540 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
ABUILDING
DDRESS APPLICATION & PERMIT
Cl ��
. � ADDRESS
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
s
IOM LIZ"ER40
AN CHECK VALIDATION
NAMEr QTY. ELECTRIC PERMIT FEE
PHONE
'V�/
CONTRACTOR UTLETS-SWITCHES-RECEP 10.00/1.00
7X Is r^ uc.ND.[I LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S
/ ADORES-- APPLIANCES-RESIDENTIAL 4.00
h(` PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
oR PANELS (OVER 200'AMP) 20.00
ENGINEER Sri tIM4 S , „
• (!AL .rvo. SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION
ADDRESS - SPECIALCIRCUIT 5.00 ..,
zlv EMP.METER OR POLE INS. 20.00 ��
9-
APPUCANT'S MOTORS SEE FEE SCH. L�
ADDRESS _ l
SERVICE CHANGE 20.00 ))/
° ¢ TEMP.POLE 30.00 /4- !
ro`O LICENSED CONTRACTORS DECLARATION
a u 1 hereby affirm that I am licensed ander provisions of Chapter 9 ISSUANCE DATE
v~i G w (commencing with Section 7000)Of Division 3 of the Business and BLDG. ELECT. PLG:. MECH.
F m z Professions Code. nd license is in full farce f e
o0 w o Lirense Class -z._I_Lie Number_
L Wt Date ConUtiECLARgy_N.e1.r_� µTr
¢ Y
¢ ¢ a OWNIi R-BUILDER DECLARATION BUILDING PERMIT
a o u, u INFORMATION
X ; a H I hereby al firm that I am exempt from the Contractor's License MISC.- REFER TO ORD
HLL0 J Law for the following region.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 1000 •s1 VALUATION $/FT.
Code:Anycity orcounty which requiresa permit toconstrueLalter.
¢ uu Q° Improve,demoinh,or repair any structure,prior tO its Issuance,also ELEC.CONTE. LIG NO. ELEC �ff1D
u w m ¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
A the is licensed pursuant to the provisions of the Contractor's License
H z A Law(Chapter 9s(cmnmencing with Section 7000)ofDivision 3 of'the
4 ° 13usiness and Prufc.asions Code)or that he is exempt thurufnnn urd QTY. PLUMBING PERMIT FEE
¢ H $
In,basis for the alleted exemption.Any violation of Section 7031.5 r ST61RIES 'EyPt CONSTR.
a ; _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00 J
of not more than five hundred dollars(S500k):
❑ L•as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP AES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and ProfessionsDRAINS.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 or through his own employees,provided that such"" xwv-
unsarenotintendedorOffered for Sala it,however,to budding GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
orimprovem°it is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or int- GAS-Eq.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
posve for purpose ofsala.). RES IND CON PB Other
'0 I,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 0 ❑ 13 E] 11
licensed Contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:'fhe 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 contructons)licensed purstwnt to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's Licen.0 Luw. TRACT NO, PARCEL NO.
❑ .I am oxampt under Sea ,B.&P.C,fihr this WATER HEATER W/VENT 6.00
anon
Owner Date WATER SYSTEM - 5.00
ACC.GATE ACG FILE NO.i
W'ORKERS'COMPENSn'TION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of cim,ent m self-insurc. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Igsur�nee,or a certified
Copy thereof IScc.3800,Lab.C.l
Policy No. Company
❑ Certilied ' is here y niched. FIRE$PRINK ENERGY T44
Z Z 0 Certifi• copy with the c' inspection division. MISC.- REFER TO ORD.
O Applicant Y [] NY . NEI
jr CERTIFICATIi OF L 'E NPT ICON FROM WORKERS' PERMIT ISSUANCE 10.00FLOOD ZONE A.L.U,C.
LU �_ COMPENSATION INSURANCE, PLG.CONTE. LIC.NO. PLG.
O (This section need not be emnpleted if the permit is for one TOTAL Y❑ NE] YE] NE]
Z hundred dollars IS 100)or Ies.J
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any purslm in any manner so as to
Ow become subject to the Workers'Compensation Laws of California.
a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} rn NOTICE TO APPLICANT: If,after making this Certificate of Ex-
H Z 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
V Such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONS'IRUCTION LCNDING AGENCY AIR HANDLING UNIT(OVER 10=C:F.M.) 6.00 SEISMIC FEE
hereby allinn I the
there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the ,Ci,.C.). of the work for which this permit is issued(Scc. MICROFILM
3097.is Na). HEATING UNIT(TO 100,000 6.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's address ELECTRIC
I certify that I 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-C)MP(3 H.P.or100,000B.T.U.) 6.00
above- authorize representatives of this city I.e' en,
er upon the BOILER-COMP.IOver 100,000 BTU)SEE FEESCH. MECHANICAL
herebyn enlioned property tativor inspection i purposes.
(We) agree to save. indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, ' is and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in an a ay accrue ainst said y in consequence of the
granfin his pc n 1 MECH.CONT. LIC.NO. MECH. p
TOTAL TOTAL 0
Sinature OfVPPUCn or DITC
INSPECTOR COPY