8731 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT 1 DENTI FICATI ON PERMIT NUMBER
D
ADRESSILDIN APPLICATION & PERMIT . 8731
l
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
�/ OWNER'S PLAN CHECK VALIDATION
N`(AME ./A ,/ - QTY. ELECTRIC PERMIT FEE
NTRAcroRs
NOME UTLETS-SWITCHES-RECEP 10.00/1.00
C/•�.5 J CO• LIC.NO. LIGHTING FIXTURES 10.00/1.00
corvrRAcroR's Q`L APPLIANCES-RESIDENTIAL 4.00 ,
PO
DRES
/y/C
ry -///� 4,
/N49PHONE)z /- / PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.'NO.
OR
ENGINEER
LIC.rvo. SIGNS TRANS. 3.00
ADDRESS ENc' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP rTEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
C Or o 0 LICENSED CON'I'RACIORS DL'CLARA'I'ION
TEMP.POLE 30.00
¢o is I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE GATE
Nw •lcommencin will, Section 7000)of Division 3 of the Business and
a ,. X BLDG. ELECT. PLG. MECH.
F w 2 Professions Code,and my license is in full force and effect ❑ ❑ ❑
Z o m - Licens ass-7 Lia Number
2 Z r Du1 5�CDntractor
a x f
_T
BUI DING PERMIT
IS ¢ a OWNER-BUILDER DE ATION
A o a u INFORMATION
w N 1 hereby affirm that 1 um exempt from tire Contractor's License MISC.- REFER TO ORD
ac o j Law for the following reason.(Sec.7031.5,Business and Prolcssions PERMIT ISSUANCE 10.00 VALUATION $/FT.
Code:Any city or county which requires a permit to construct.alter,
IS
a, i o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC
O IS regairet(lie applicant for such permit to file a signet)statement that TOTAL ' /- PER
La IT TO
e m he is licensed pursuant to the provisions of the Contractor's License /'
La Z i Law(Chapter 9(commencing with Section 7000)of Division 3 of the
a Baoiness and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
i a
e. o the basis for the alleged exemption.objects
Any violation of Section malty ST RI 5 TYPE CONSTR.
n ;m by any applicant fora permit subjects t SOO).)icanuoacivil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not marc than live hundred Jolla¢(my em):
❑ Las owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC. ROUP R 5.UNITS
their sole r offered
compensation, (S the work and the structure is not
intended or offerer) for sale (Sec. doe Business and Professions DRAINS-FLOOR,ROOF,AREA,GOND. 5.00
Cod e Thu 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
• himself re through his own employees,for
provided that such improve
routs are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement Is sold within one year of completion, the own or- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
build will
ION have the burden of proving that he did not build or int- BUILDING USE
for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
v 1,as owner of the property,wn axalusivcly contracting with ❑ ❑ ❑ ❑ ❑
li I sed 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
lu an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractous)licensed pursuant to
the Cont r ctor's License Law. , SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ Ira armptunder Sec._ .B.&P.C.for this WATER HEATER W/VENT 6.00
al
'Owner%C Dat WATER SYSTEM 5.00/ � � '� ACC.DATE ACC FILE N0.
WokKERS'COMI'F,NSA'I'ION DECLARATION WATER TREATING EQUIP. 5.00
I Imreby.affirm that I have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,LmhC).
Policy No. Company
O ❑ Certified copy 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❑ V ❑ N❑
CC T CERTIFICATE 017 EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG,
0- 0Z I Uu, section need not be completed if the permit is for one TOTAL v❑ N❑ Y ❑ N❑
hundred dollars(5100)or lass.)
U O 1 certify ti:u in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I s11a11 not employ any person in any manner so As to
Ow become subject to the Workers'Compensation Laws of California. BUILDING
Q. U°ter Applicant ALTER OR ADD TO MECH. 5.00
} W NOTICE 'f0 APPLICANT: If,after making this Certificate ul 17
F'- 2 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
U ,such provisions or this pernhlt shall be deemed revoked AIR HANDLING UNIT(TO 10=CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10A000.F.M.) 6.00 SEISMIC FEE
I hereby affirm that titre is a construction Icndlng agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). 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 NAcidic,ames ELECTRIC
I certify that 1 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-OOMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the r"
above-mentioned property for inspection purposes. BOILER-COMP IOsar 100,000 BTU)SEE FEE$CH. MECHANICAL
(We) agree to save, indemnify and keep haroless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
N
y in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
ran ing of t) p• nit. , MECH.CONT. LIC.NO. MECH.
V• s TOTAL TOTAL
vt 'S lure ,f Applica"/Contractoriioom Date �,, ��
/J` INSPECTOR COPY