C8710 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON - PERMIT NUMBER
ADDRE"SSG APPLICATION & PERMIT 8 1
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
1 OWNERS Ctt"�IPS AN CHECK VALIDATION
"AME QTY. ELECTRIC PERMIT FEE
ONE
rvCONTRACTOR
Across
awOUTLETS-SWITCHES-RECEP =0/1.00
! Lica NO. LIGHTING FIXTURES 10.00/1.00
DScroFs
ADDRESS
PPLIANCES-RESIDENTIAL 4.00
CONT AC
PHONE PANELS 10.00 DATE OF APPLICATION
RRLHITECi PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC,NO. SIGNS TRANS. 3.00
ADDRESS END SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 n
APPLICANTS MOTORS SEE FEE SCH.
ADOR ESS
SERVICE CHANGE 20.00
o ¢ ZIE �5
7 /
F o o LICENSED C'ON"TRACTORS UECLA RA'HON ! TEMP.POQE 30.00 d
< v u I hereby affirm that I am licensed under provisions of Chapter 9 1, f ISSUANCE DATE
m z w (commencing with Section 7000)of Division 3 of the Business and
/ BLDG.. ELECT. PLG. MECH.
P,y
H N z Professions Code,and my license is in full folie and effect ./ ❑ ❑
2 o m - License Class Lic.Number
2 y t w Datr Contracmr
a Y ISLI 'ti) BUILDING PERMIT
at ¢ w¢ OWNF-R-BUILDER DECLARATION
A o A u MISC.- 1 REFER TO ORD .INFORMATION f
X g.- I hereby affirm that I um exenspt from Om Contractor's License ;
Cr Law for the following reason, 7031.5.Businessand Professions VALUATION $/FT. r.
_ PERMIT ISSUANCE
wy Code:Any city or county which rcquiresa permit toconstruct,alter,
Q4, ¢ Improve,demolish,or repair any structure`,prior to Its Issuance, bo ELEC.CONTR. / LIG.NO. %LEC. 6011)
0 ¢ occur...the applicant for such permit to file a signed statement that f TOTAL /(ti ER IT TO
La m he is licensed pursuant to the provisions of the Contractor's License '
H z i
Law(Chapter 9(commencing with Section 7000)olDivision3 ofthe l //�1
4 o Business and Professions Code)or that hK
e is exempt therefrom end QTY. PLUMBING PERMIT FEE a zo)<7< (3
¢ m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a by any applicant for a permit st hite s the applicant Ina civil penalty ALTER-DRAIN& VENT-WATER IEA.) 5.00
of not more than five hundred dollars(5500).)'.
❑ 1,as owner of the property,or my employees 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 or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00 .X ,
Code:Tho Contractor's License Law docs 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 re through his own offered
fors,provided that such improve-
ments himeare not through his ornemploeesale.provided
that such
building GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,Ole owner - . - . .00- GAS EASYSTEM OVER 4 (EA) 2
builder will have the burden of pronng that he did not build or im- BUILDING USE
RES IND CON PB Other
prove 1,aso neeose of the
INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑
❑ I,as owner of the property,nm exclusively contracting with
licensed contractors to construct the project(Sec. 7044, Btsiness LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO
andProfessions Codi:The Contractor's License Law does not apply
to an owner of property who builds or improves therron.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such project with a contractor(S)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License awn TRACT NO. PARCEL N0.
❑ aI xempt undo ,B.&P.C.for this
WATER HEATER W/VENT 6.00
reason
T own Uatr��' WATER SYSTEM 5.00 ACC.DATE ACC.FILE N0.
WORK E RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 41 1
I hereby affirm that I have a certificate ofconscnt to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lah.C.).
Policy No. Company
U ❑ Certified copy is hereby furnished.
z Z ❑ Certified copy is filed with the city' inspection division. FIRE SPRINK ENERGY T-24.
O Applicant MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
CC W CERTIIICA'r Ii OF EXEMPTION 1*ROM WORKERS' PERMIT ISSUANCE 10.00 PLOODZDNE A.L.U.O.-
LI > COMPENs A'DON INSURANCE PLG.CONTR. LIC.NO. PLG.
CL Z( This section need not he completed if the permit is for one TOTAL Y❑ N❑ Y❑ N
hond...I dollars IS 100)or less.)
CTO 1 certify that in the pert imnunce of Ole work for which his per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY ss
LL H mil is issued,1 shall not employ any person in any manner so as to
U W become subject to Elie Workers'Compensation Laws of California.
Q. Dxtc Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE '1'O APPLICANT: If,after making this Certillcam of Ex
F 2 emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK b
provisions of the Labor Code, you must forthwith comply with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 FEE pO,
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVERIOJWOC.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 It,
the 3097,performance
CivC ante of the work for which this permit is issued(See. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM !/
Lender's Name
Lender',AddreH EATI NG LIN IT IOVER 100,000 B.T.U.)9.50 ELECTRIC
ss
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 �.
infer nmtion is correct.I agree to comply with all city and county PLUMBING �.
ordinances and state laws relating to building construction, and BOILER-COMPO H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to corer upon the BOILER-COMP (Over f00.0008TU)5EE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes. s
(We) agree to save, indemnify and keep harmless the City of misc.- REFER TO ORD.
Cupertino against lijpities,judgmmnts, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may any way a erne against said city in consequence of the
gr goflhi,r I 'L MECH.CONT. LIC.NO. MECH.
/ rx
v/gr TOTAL TOTAI e
.gnatum of pylic nl ontmcl r at �v
INSPECTOR COPY