9353 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
But LDING APPLICATION & PERMIT 8353
AoonEss
BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
GORE 5 � IAPLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
vHONE
CONT Cr ns
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
uc.No, LIGHTING FIXTURES 10.00/1.00
ADDRESS ons fl PPLIANCES-RESIDENTIAL 4.00
PNoNE PANELS 10.00 DATE OF APPLICATION
IE
an PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
EOR
SPECIALCIRCUIT 5,00 PERMIT VALIDATION
ZIP fTEMP.METER OR POLE INS. 20.00
APPLICANrS
ADDRESS MOTORS I SEE FEE SCH.
Oness
SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATION TEM PIP LE 30.00
c U v 1 hereby affirm that 1 am licensed under provisions of Chapter 9 roV ISSUANCE DATE
m <H (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F H z Professions Code,and my license is in full force and effect.
0 o m - De"'J.Class �_Lia Nwnbc� ❑ ❑ El 1-1O Dam Contractor
a x f BUILDING PERMIT
p m w u OWNER-BUILDER DECLARATION
A o A MISC.- REFER TO ORD INFORMATION
ce 3 a- I- I hereby aft irin thin I um exempt front the Contractor's License
u 0`< Law for the mllowing neon.IS,,,7031,5,Ilusinesseud pm fessions PERMIT ISSUANCE 1DA0 VALUATION
- Coda.Any city or county which requiresa permit toconstrucn,alteq
R ¢ ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO, ELEC. �
C,a, requires tl,e applicant for suCII pefnut to file It signed statement that TOTAL PERMIT TO
w es he is licensed pursuant to the provisions of the Contractor's License
LU
rzi w(Clmpte,9(emm,encing with Section 7000)of Division 3 of the
a' Business and Profoions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE �" ��
r o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
d3 °�a by any applicant for U permit subjects the applicant loo civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of non more than five hundred dollars($500f)
❑ 1,as owner or the property,or my entpbyces will,wages as BACK FLOW PROTECT. DEVICE 4.00 Dec.GROUP RES.UNITS
their 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 -r'
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT FLOOR AREA TOTAL ACREAGE
meats are of ugh intends own emred for Sale.
If,ed however.
the
improve- GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00 Jr
meets are not intended or offered ba sale.If,Im pleb,-the building
or improvement is sold within one year of completion,the owner-00 GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving flathe did not build or im-
prove for purpose of sale.). INDUSTRIALWASTE INTER. 30.00 RES IND cOry PB Omer
❑ I,as owner of the property,am exclusively contracting with ❑ E:] ❑ [:] . E:]
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 properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
ContractS for such projects with a conlractods)licensed pursuant to
the Contract.,',License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ l am exempt under Sec.-,IL&P.C.for this WATER HEATER W/VENT 6.00
reason
Ownc, Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate ofconsLGt to self-Insure'
or a certificate of Workers Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3500,I.A.C.).
Policy No. Company-6 AZx�n
Q ❑ Certified copy is hereby fu nu shed. FIRE SPRINK ENERGY T 24
Z ZAy ICCertificd 6py is Iil•d. with the city inspersion division. MISC.- REFER TO ORD. ❑ ❑ ❑ ❑
Q T N N
(r N CF: TI OF hXCMPI'ION PROM WORKERSPERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LL > COMPENSATION INSURANCE PLG.CONTR. UC.NO. PLG.
d 0 This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ IN
0 Z hundred d.11ho,(5100)or les,,)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
U_ F mil is Marc, 1 shall not employ any person in any Gimme, .as to
U become subject to the Workers Contpensutinn Lows of'California.
a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} m NOl'ICE 1'0 APPLICANT. It,after nuking to,Cenifi,me of I,x-
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
U 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 IQOWC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of life work for which this permit is issued(Sec. MICROFILM
3097,Civ.CJ. 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 0-V
1 certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
ordinances n estate,.1 agree to comply with all city and county PLUMBING
ordinances and state lows relating to building construction, and BOILER-COMP I3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 10°,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,judgments, costs and expenses which CONST.TAX
may in any�wdy accruy iigaidst said City in consequence of the PERMIT ISSUANCE 10.00
grant ingi5 permjL MECH.CONT. LIC.NO. MEOTCH,
T "` TOTAL
- Ignatbremt' pplderrtp on frac for Date
INSPECTOR COPY