C8490 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENT]FICATION PERMIT NUMBER
RUILDING APPLICATION & PERMIT O
AODREss
/ BUILDING
- ELECTRICAL-PLUMBING-MECHANICAL
OWNER A PLAN CHECK VALIDATION
\C NAME \ DTV. ELECTRIC PERMIT FEE //�J,'
%Ii
NAMERacroR P UTLETS-SWITCHES-RECEP 10,00/1.00 U
•� Llc.No. LIGHTING FIXTURES 10.00/1.00
ADDREACroRss s APPLIANCES-RESIDENTIAL 4.00
ADORE
PHONE 3 711- PANELS 10.00 DATE OF APPLICATION
iORRCHITECT / 1 PANELS (OVER 200 AMP) 20.60 PLAN CHECK FEE P.C.NO,
ENGINEER
LIC.No. SIGNS TRANS. 3.00
A DRESS N SPECIAL CIRCUIT 5,66 PERMIT VALIDATION
zIPrrEMP. METER OR POLE INS. 20.00
D L MOTORS SEE FEE SCH. r- 1
ADDRESS J
SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
c Z nI hereby affirm that I am licensed under prmislons of Chapter 9 ISSUANCE DATE
(co
a mmencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH
H i Professions Code,and my license is in full force and effect.
,.Z o w - License Clair .__ Lich Nhmber r n +� q'
' o w F w Date Contractor Ioio/4
a t< s < 'BUILDING PERMIT
¢ ¢w a OWNER-B UILDIiR DECLARATION -
INFORMATION
3 LL N I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD %!
Fu0J Law for the following reason.(See.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
ac Code,Any city or county which requires a permit to construct,alter,
.�
¢ ¢
At O improve,demolish,or repair any structure.prior to its issuance.also ELEC.CONTR. LIC.NO. ELECT
¢ requires the applicant for such permit to file a signed statement that TOTAL
u ' 9 p TO
E
m he is licensed pursuant to the provisions of the Contractor's LicenseRMIT
r z a Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe AL�Q/i.0,, Or
i o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE x1�eleaa
fe F$ the basis for the alleged exemption.Any violation of Section 703 t.5 STORIES TYPE CONSTR.
e. 3 _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not morn than five hundred dollars(S50OL):
❑ I,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,AR EA,COND. 5.00
Code: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 ACR EAGE
• himself or through his own employees,provided that such improve-
ments are not intended or o0'ered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 200
builder will have the burden of proving that he did not build or im- . BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 RES IND CON PB Omer
❑ 1,as owner of tire . .
e property,am exclusively contracting with E]
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.8. 6.00 ASSESSORS PARCEL NO.
and Professions Code:'fire Contractor's 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 contructons)licensed pursuant to SEWER-SAN V-STORM EA.200h/10:00
the Contractor's License L.W. TRACT NO. PARCEL NO.
❑ lam exempt wsder Sec. ,R.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORT:ERS'COMPENSAFION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure,
or a conifsctic of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(See.3800,Lab.C.L
Policy No. • Company
q, ❑ Certified copy is h ereby furrif5luid. C, FIRE BPRINK ENERGY T24
�-� Z ❑ Cerlif'ie Up : filed with he city insp-c on division.
J MISC.- REFER TO ORD.
e0\ Applicant V N Y N
mIt, PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.c.
CC QiR IIICATIi P EXEMPTION'FROM WORK ERSk.O v
LU > COMPENSATION INSURANCE PLG.CONTR. LIC,NO. PLG,
a O (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N�
::� Z hundred dollars(S 100)or less.)
C) O 1 eerily that in the mrf,or,,P,o of the work forwhich this per- CITY. - MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,1 shall not employ any person in any manner so as lo
U become subject to the Workers'Compensation Laws of California.
ED Datc Applicant / BUILDING
} to NOTICE '10 APPLICANT: If,after making this Certif¢ate of Ex- ALTER OR ADD TO MECH. 5.00
F Z_ emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 1 PLAN CHECK
pr on
of the Labor Code, you nulst forthwith conply with
U such provisions or this permit shall be dee nwd revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 FEE t
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'purfbnnanee of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.), I HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Address
H EATI N G LIN IT(OVER 100,000 B.T.U.)9.50 DU
Lender's Address 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
hereby authorize representatives of this city to enter upon the BOILER-COMP IOvei 100,000 BTU)SEE FEE SCH. MECHANICAL
- above-manlioned 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 City in consequence of the
grant, flh' pe it. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
\`/ I IrL`nl at r'CO at
INSPECTOR COPY