C8414 -APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT I DENTI FICATI ON PERMIT NUMBER
X BOILOING APPLICATION & PERMIT
ADDRESS (�
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 6T.41414
OCR PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE �A yK�
49 #A AjCG IF PHON L
NAMER ° OUTLETS-SWITCHES-RECEP 10.00/1.00 ( r
LC.No, LIGHTING FIXTURES 10.00/1.00
CONTRACTORSRESSAPPLIANCES-RESIDENTIAL 4.00
AD N
PRONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT ' - PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.Na.
ENGINEER '
LIC.No.' SIGNS TRANS. 3.00 '
ADDRESS Ervc. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT'S
ADDRESS
APPLICANTS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
o L) LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
G u U 1 hereby affirm that I am licensed under provisions of Chapter 9 _ ISSUANCE DATE
wa (commencing with Section 7000)of Division 3 of the Business and
¢ SFr-' BLDG. ELECT. I PLG. MECH.
Hp i Professions Code,and my license is in full force and effect. y E]
z O se - License Class Lic.Number .. El 1:1
0 w - o Data Contractor
a x BUILDING PERMIT
ne ¢ ¢ OWNER-BUILDER DECLARATION
a w v INFORMATION
E
;e, ti I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
.. o¢ Law for the following reason.(Sec.7031,5.Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
LYNN -' Code:Anycilyorcoumywhichrequiresapermittoconstruct,alter, 00
¢ 2 G O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC,NO. ELEC.
¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
T
m u he is licensed pursuant to the provisions of the Contractor',License
rz > Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
¢ Business and Professions Code)or that lie is exempt therefrom and QTY. PLUMBING PERMIT FEE VO Ifa
re r o the basis for the alleged exemption.Any violation Of$eetior 7031,5 ST(5hltg T E C BTR..
a ; °_' by any applicant fora permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.),,,5.00
of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my cmplcyces with wages as BACK F LOW PROTECT.DEV ICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is net
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractor's License Law docs not apply to an owner of x`1
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 SO.FT.PLOOR AREA TOTAL ACREAGE
a himself or through his own employees,provided that such improve- ,
mems are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INCA OUTLETS 6.00
or improvement Is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2:00
builder will have the burden of proving that hote did nhuild or im- BUILDING USE
piovc for purpose of sale.). INDUSTRIAL WASTE INTER. . -30.00 E5 IND CON PB Other
❑ J,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the pmjeer(Sec c 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The CommuR',License Law docs 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 contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft 10.00
tine Contractor's License Law. / TRACT NO. PARCEL NO.
❑ I am exempt andcrSri. ,B.&1'.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date Lf - WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WOROWCOMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of cunsent to sef-inarre.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.T
Policy No. Company
O ❑ Certified copv is hereby furnished FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with the city inspection division. MISC- REFER TO ORD.
O Applicant Y ❑ N❑ Y ❑ N❑
~ mPERMIT ISSUANCE 10.00
Lu - CERTIFICATE 01:EXEMPTION FROM WORKERS' FLOODZONE A.L.u.c.
W > COMPENSATION INSURANCIi PLG.CONTR. LIC.No. PLG.
CL O This section need not be Completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
D Z hundred dollars IS 100)or less.)
i U O 1 certify that in the Performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
$)_ H (nit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Com unisation laws of California.
Date A (cant BUILDING
m NOTICE 'f0 APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00 Jv
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
. 51 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 10,000OF.M.) 6.00 SEISMIC FEE 'D
1 hereby affirm tha [here is a construction lending agency for EXHAUST HOOD (WITH DUCT)' 5.00 J "
the performmnce of the'work for which this permit is issued(Sec. MICROFILM
l 3097.Civ.C.). I 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
I ccrtily that I have read this application and state that the above VENTILATION FAN (SINGLE) $.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and Into laws relating to building construction, and BOILER-COMP(3H.P.or100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(over 100,000 BTU(SEE FEE SCH. MECHANICAL
r 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 PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against Said th
City in consequence of e t
granting of this permit. MECH.CONT. LIC.NO. MECH.
\ TOTAL TOTAL 3 w
Signature of cant/Confracmr AppliDate
INSPECTOR COPY