8323 APPLICANT TOIFILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
AooR ss 1111n -{' BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 83.23
OWNER'S / PLAN CHECK VALIDATION
NAVE PHONE
ELECTRIC PERMIT FEE J
.. PHONE S
CON Ac o 1
NAME UTLETS-SWITCHES-RECEP 10.00/1.00
/
/) LIC... LIGHTING FIXTURES 10.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
ADD Pas f� ^/
4,(5S PHONE I /D PANELS ' 10.00 DATE OF APPLICATION
N
An
OR HIT T PANELS (OVER 200 AMN 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO, SIGNS TRANS. 3.00
ARCH,OR ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 20.00 /
nova SSTs MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 /
o O o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
<u U I hereby affirm that 1 am licensed under provisionsof Chapter 9 ISSUANCE DATE
h 3 u (Commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECN.`
H-o z Professions Col n license is in full fort e e�te7
z o H License Clazs J Lie.Number < ❑ ❑ ❑� ❑
o w r Date Contractor
y s _,L1
_ BUILDING PERMIT
le w T OWNER-BUILDER DECLARA'I'IUN �+ INFORMATION
Koa MISC.- REFER TOO
a 1 hereby afOnn that I wn exempt frmn the Contractor's License
.. o¢ Law for the following reason. 7031.5,Basin...and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
I - 0 ` Code:Amycity orcounty which requires a permit to construct,alter,
QO improve,demolish,or repair any structure:prior to its issuance,ala. ELEC.CONTR. LIC.N0. ELEC.
na
- D M requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w m" he is licensed pursuant to the provisions of the Contractor's License
Law(Chapter 9(commencing with Section 7000)o(Dreision 3 ofthe i r
4 o QTY. PLUMBING PERMIT FEE
Business and Professions Code)or that he is exempt therefrom and
IL H o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
ca
ate _ by any applicant for a perm it subjects the upph,.nt to a emincoally ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than live hundred dull...(5500).1:
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00 OCC.GROUP - RES.UNITS
their sole mm pens'afion,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 Contractors License Low does not apply to an owner of f
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 ,50.FT.FLOOR AREA TOTALACREAGE
_ himself or through his own employees,provided that such improve-
mentsarenotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-l1NC.40UTLETS 6.00
.",.Provelnmt is sold within one year of completion,.the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING JSE
blder will have the burden of proving that he did not build or im- RES IND CON PB Other
prove for purpose nl sole.). INDUSTRIAL WASTE INTER. 30.00
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the,project(Sea. 7044,BusinessLAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractors License Law docs not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OV ER 5(EA.) 1.00
contracts for such projects with a madractor(s)licensed pursuant to
If,,Contractors License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
Cl Imnexemptunder See. ,B.&P.C.for this WATER HEATER W/VENT •6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC FILE NO,
WORK ERS'COMPFNSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificale of consent to self-insure. ZONING
or a certificate of Workers'Compensation Insurance,or a certified
ENG.SITE N0.
copy thereof(Sec 3 0 dap CJ.
I'olicy No ny
O ❑ Cc it ted copy is rereby furnished. FIRE SPRINK ENERGY T-24
❑ Certified e) . fled with the city inspectiolt.division.
zp Applicant F t MISC.- REFER TO ORO. Y ❑ N❑ Y No
0: y CERTIFICATE OI'1 XFMP`r1ON FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.UG
IL > COhIPFNSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
Z (This section need not be completed if the permit is for one TOTAL D,� v❑ N❑ Y ❑ N❑
hundred dollars IS 100)or less.)
U 0 1 certify that in the performance of the work for which this per QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U unit is issued, I shall not employ any person in any manner so as to
become subject to the Workers'Compernsatiun Laws of California.
O a Date ApplicantALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of IN.
F ? mnption,you should become subject to the Workers'Compcnsmion APPLIANCE 5.00 a 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 10MCF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.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 the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Nome
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that l 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 stale laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 •O
• hereby authorize representatives of this city to enter upon lire BOILER-COMP (Over 100.000 BTU)SEE FEE SCM. 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 1 any way accrue against said sty.in co equene, of the PERMIT ISSUANCE 10.00
'4.11C
ollh is pent»t MECH.CONT. UC.NO. MECH,
Q TOTAL TOTAL
Sign re o pp cant Con r E o /arc - -'O•�
If U INSPECTOR COPY...__-