8497 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
,1008 E55 A
BUILDING - ELECTRICAL-PLUMBING -MECHANICAL t`f4,
OWNER'S [J/yQ PLAN CHECK VALIDATION
CITY. ELECTRIC PERMIT FEE
ONE
mAmeA 102&OUTLETS-SWITCHES-RECEP 10.00/1.00 �
_LIC.NO. LIGHTING FIXTURES 10:00/1.00
OTORS
APPLIANCES-RESIDENTIAL 4.00 .S(
CONTRA
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMPP
) 20.00 LAN CHECK FEE P.C.NO,
OR
ENGINEER
uc.No. SIGNS TRANS. 3.00
AARCH,OR DDRESS ENG SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
APPLICANT SMOTORS SEE FEE SCH. }'L
ADDRESS
d SERVICE CHANGE 20.00
q f i
Co o LICENSIiD CONI"R ACTORSDIiCLARATION TEMP.POLE 30.00 Ta I u S
a U v I hereby afliou that 1 ant licensed under provisions of Chapter 9 ISSUANCE DATE
y G w (conuneneing with Section 7000)of Division 3 of the Business and Y. BLDG. ELECT. PLG. MECH.
F m z Professions Code,and my license is in full force and effect. ❑
zo 0 as o License Class Lic.Number
IJoto Contractor
¢ m f BUILDING PERMIT
¢ ¢ w u OWNER-BUILDER.DECLARATION
a o A MISC.- REFER TO ORD INFORMATION
X LL H I hereby drily, that I wn exempt firma the Contractor's License VALUATION $/FT.
H LL 0 4 Law for the following reason.(Sec.7031.5,Businessland Professions PERMIT ISSUANCE 7¢00
Code:Any city or county which requiresa permit toconstrucL alter,
SE rc ¢ O nmprove,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIG NO. ELEC. �^
O LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w mhe is licensed pursuant to tine provisions of the Contractors License
H- zQ Law(Chapter 9(commencing with Section 7000)ol Division 3 ofthe t, 4-{=c-7• J�(r
E 0 Business and I'mfussions Code)or that hfr
e is exempt thcrcom and OTV. PLUMBING PERMIT FEE
¢ I- a the basis fur the alleged exemption.Anv violation of Section 7031.5 STORIES TYPE CONSTR.
n � re by any applicant for a permit subjects the applicant Or civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars($500)1)'.
❑ 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,AREA,COND. 5.00 ,
Cade:The Contractor's License law does 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
Ifir,,its re Rdthrintended
own employees, If,h that such improve- GAS-EA.SYSTEM-I 6,00
or
are notintended orofferedthinon yearsale.If,completion
the building .CL
or ire r will have
is sold within one year of he dietio t the owner- GAS-EA.SYSTEM-OVER 4 (EA,) 2.00 BUILDING USE
builder will have the burden of proving that he did not build ar ire- RES IND CON PB Omer
prove for purpose of sale., INDUSTRIAL WASTE INTER. 30.00 El El 0 El E]❑ ed as owner of the property,hexclusively contracting with
licensed contractors to construct the e project 7044,Business LAW N'SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code'flm La Contractor's License Law Joos not apply
' to ran owner of property who builds or improves therton,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractm(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ I;un exempt under Sec. BAP.C.for this WATER HEATER.W/VENT 6.00
eason
Owner Date WATER SYSTEM 5.00 11
L. ACC.DATE ACC.FILE NO.
KIiRS'COMPENSATION DECLn ItA'TI WATER TREATING EQUIP. 5.00
I here affirm that I have a certificate of-consent to sel Ginsure.
or a certificate of Workers'Compensation Insurance,or a certilied ZONING ENG.SITE NO.
Copy thcoad'(See.3800,Lab.C.).
Policy No. Company
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with lire city inspection division.
O Applicant MISC- REFER TO ORD. vNYE] N�
CC C E KI I P I CA'FE O I°li%I MPT ION PROM WORKERS' PERMIT ISSUANCE 10 00 FLOOOZONE A.L.U.C.
W D COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y N� V N�
Z (This section need not be completed if the permit is for one TOTAL /SG
hundred dollars($100)or less.)
U O 1 certify that in the performance of the work Ibr which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any nm tuner so as to
�_1O w men
becomes object to tine Workers'Copsation Laws of California.
C. Date APPIRr ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE 'f0 APPLICAN"r: If,after making this Certificate of Ex--
F" ? emption,you should become subject to the Workers'Compensation I APPLIANCE5A0 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
CONSTRUCT ION LENDING AGENCY AIR HANDLING LIN IT(OVER 1OPM C.F.M.) 6.00 " SEISMIC FEE
I,hereby affirnn that there is a construction lending agency far EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(See. MICROFILM
3097,Civ.C1). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATI NGUNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read thisapplication and state that theubovc 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-OOMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorise representatives of this city to enter upon the BOILER-COMP (Over 100,000 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 slid expenses whichCONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00 --
granter Of this permit MECH.CONT. LIC.NO. MECH,
TOTAL C� TOTAL
Sign i'a't onlractor aWIF
INSPECTOR COPY