8316 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECTlDENTIFICATION APPLICATION & PERMIT PERMIT NUMBER
NOORBUILDING
noon Ess �,
BUI 6
-� G - ELECTRICAL-PLUMBING-MECHANICAL 8316
OWNER' PLAN CHECK VALIDATION
NAME .q QTY. ELECTRIC PERMIT FEE
T R. ONE
NAAM pRncroRs UTLETS-SWITCHES-RECEP 10.00/1.00
61LIC.NO / LIGHTING FIXTURES 10.00I1.00
CONTRACTORA7; pPLIANCES-RESIDENTIAL 4.00
C,/
J7 PHONE _� _ PANELS 10.00 DATE OF APPLICATION
n curtscT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO SIGNS TRANS. 3.00
moo Ess ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
AASS
ADDRESS
MOTORS SEE FEE SCH. J
Q
SERVICE CHANGE 20.00 V e/
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 Y�✓/p ,f J
' Q U U I hereby affirm that I am licensed under provisions of Chapter 9 - ISSUANCE DATE
y Q a (commencing with Section 7000)of Division qp. ,(Business and SLOG. ELECT. PLG. MECH.
F m i Professions C end my ' cosi is in full for nd.e ❑ ❑ ❑
z o License- Llcee Class Lie.Number d
O w Date Contractor
¢ r f� BUILDING PERMIT
¢ ¢w a OWNER-BUILDER DLCLARA'I'ION INFORMATION
MISC.- REFER TO OR
w 3 LL H 1 hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
Fu Oj Law for ilii following reason,(Sec.7031.5.Buinessand Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
QQ ¢ p improve,demolish,or repair any structure,prior 10 Its Issuance,also ELEC.CONTR. LIC.NO, ELEC.
iL m¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
o. w u. he is licensed pursuant to the provisions of the Contractor's License ^
2 i Law(Chapter 9(commencing with Section 7000)of Division 3 of the
4 o Business and 1'rotessim.Code)or that he is exempt Iheretrom and QTY. PLUMBING PERMIT FEE
¢ I-o the basis for the alleged exemption.Any violation ofSectioa 7031.5 1 STORIES TYPE CONSTR.
n ;m by any applicant fora permit subjects the applicant to a civil penahy
of not more than five hundred dollars($5001./: ALTER-DRAIN& VENT-WATER (EA.) 5.00
O 1,as owner of the property,or my empluyces 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 sole(See. 7044, Business and Professions 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 SD.FT.FLOOR AREA TOTAL ACREAGE
himself re through his own erred fors,Provide) ev such improve-
merns mselfo not intended oro ffereoyeesale.Iided that r.such
building GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM-OVER 4 (EA) 200
builder will have the burden of proving that h - . . .
e did out build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
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 property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contmetons)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
lite Contractor s License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.BP.C.for this WATER HEATER VI/VENT 6.00 L �/
lemon
Owner Date WATER SYSTEM 5.00 ACC.DATE' ACC.FILE NO,
WORKERS'COMPENSAT1ON DECLARATION WATER TREATING EQUIP. 5.00
r I hereby affirm that I have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance.or certified
copy th o, POQ Lug ).
Policy c fH'npaJ)
O crti le o s hereby I'u nished. FIRE SPRINK ENERGY T 2
Z Z ❑ Certified 'o P; is fit d with the cllY inspection di ixlon.
O Appl' L i /�Ii-/ /1/�L,/y_ MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N❑
CCCC Q-T 'b-�-� PERMIT ISSUANCE 10.00
W > CI-RT1PV COMPF13 iNSATION EXEMPTION
O CWORA F;R$' PLG.CONTR. LIC.NO. PLG GTI FLODD 20NE A.LU.C.
CL o (This Section need not be completed it the permit is for one TOTAL v❑ -F-1 Y 1:1 N❑
Z) Z hundred dollars(SI00)or less.)
U O 1 ceHily that in the perfornmnee of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL k- mit is issued,I shall not employ any person in any manner so as to
Ow become subject to the Workers'Compensation Laws of California. BUILDING
o, nate Applicant ALTER OR ADD TO MECH. 5.00
} m NOTICE'10 APPLICANT: If,after making this Certificate of IN-
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
CJ such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 4.00
CONSTRUCT ION 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 r
3097 performance MICROFILM
Civ.C. of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00
f' Lender's Name
Lender's AJdns HEATINGUNIT(OVER100,000B.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 state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 OIJL)
hereby authorize representatives of this city to corer upon the
abovti neo f
BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
cmenproperty or inspection purposes.
(We) agr to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. -
Cupertino ajlmmst liabilities,judgments, costs and expenses which CONST.TAX
may in�:m w'y accrue altruist said City in consequence of the PERMIT ISSUANCE 10.00
granting of hr flltil MECH.CONT. LIC.NO. MECH. /l
/ TOTAL TOTAL 4v
Sigrl u o'Applicanl/ omrac(bg
' - INSPECTOR COPY