C8637 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON PERMIT NUMBER
Ama LDINGDDRESS / APPLICATION & PERMIT /�^��
ADDRESS b
UI LDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S / / KCHECK VALIDATION
NAME r OTY. ELECTRIC PERMIT FEE
�Y PHONE
NAME Acrons UTLETS-SWITCHES-RECEP 10.00/1.00
C.No. LIGHTING FIXTURES 10.00/1.00
ADDR s ESS PP LI ANC ES-RESIDENTIAL 4.00
ColoScion
I/
Sy PHONE ] r PANELS 10.00 DATE OF APPLICATION
ARCHITECT 0
nLRITECi PANELS (OVER 200 AMP) 2 'OO PLAN CHECK FEE P.C.NO.
ENGINEER
LIC,NO SIGNS TRANS. 3.00
ARCHR. ENG. SPECIAL CIRCUIT `5.00 �' PERMIT VALIDATION
SS
zlP rFEMP.METER OR POLE INS. 20.00
AGOG FES
APPLICANT
AGOG FES MOTORS SEE FEE SCH. /`U„(
/
SERVICE CHANGE 20.00
o a LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a i w 1 hereby affirm (hat I am licensed under powisians of Chapter 9 ISSUANCE DATE
a m (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H w z Professions Co nd by license is in full force and elle
ca o m- License Clas Lic.Numbcr�� �
ca Z H w Date Contranor e'er
a m r7 BUILDING PERMIT
a o i u OWNER.BUILDER DECLARATION INFORMATION
w ;LL I- I hereby affirm that I um exempt from the Contractor's License MISC.- REFER TO ORD
uoa Law for the following reason. 7031.5.Business and Professions PERMIT ISSUANCE 10.00 VALUATION g/FT.
- Code:Any city or county which rnsluiresa Penni((ocons(nmLal(eq
2 ea¢ 0 improve,demolish,or repair any structure,prior(o its issuance,also ELEC.'CONTR. LIC.NO. ELEC.
o u requires life applicant for such permit to file a signed statement that TOTAL PERMIT TO
R
m he is licensed pursuant to the provisions oflhe Contractor's License
Law(Chapter 9(commencing with Section 7000)oiDivision 3 ofthe
i o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
r o the basis for the allcgM exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR
La n ;m by any applicant for a Penni(subjects the applicant to a civil Finally ALTER-DRAIN&VENT-WATER (EA.) 5.00 -
of not more than five hundred dollars(55001.):
❑ I,as owner of the properly,or my employees with wages as BACK F LOW PROTECT.DEVICE 4.00
their sole Compensation, will:do die.work,and file stma ctuis nut OCC.GROUP REB.UNITS
intended or offered for sale(Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:'I'tie Contractor's License Law does not apply to an owner of _
property who builds or Improves thereon,and wlh)does Such work FIXTUR ES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees, Rovidca that such�- improve-
ts meaere not intended or offered for sale.IL however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within ane your of conhple(ion, (he owner- GAS EASYSTEM OVER 4(EA ) 200
builder will have (he burden of proving thin he did not build or ire - . - . .
- BUILDING USE
prove for purpose of sale:). INDUSTRIAL WASTE INTER3000 RES IND CON PS Omer
❑ I,as owner of the properly,am exclusively contracting with . .
1:1 ❑ ❑ 0 ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code rhe Commetor's License Law does out apply
(o an owner of P,.Pon,who builds or improves tmre,m,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such Projects with a mnvnc(orfsl licensed Pursuant m
tire
Contractor's
o sLiese Law. SEWER-SANITARY-STORM EA.200ft/10.00
TRACT NO. PARCEL NO.
.❑ tum exempnmder See ,B.&I'.C.liter this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE AGC.FILE NO.
WORK ERS'CONPHNSA'TION DIiCLARAT ION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Wo{{kers'Com penwfirm Insurance,or a certified
copy lhercaf(Sec-3 00,Lub.C.).
Policy No. Company
❑ Certifln o y'is TB7Bby'f r (shed FIRE SPRINK ENERGY T 24
z'Q ❑ Ce y�s fled wilt m c in cY n division.
O ApPlicenl MISC.- REFER TO ORD. Y O NE] Y [D NE]
FrPERMIT ISSUANCE 10.00
LU - CER II'ICA'I'P P EXEMPI9ON.FRO. -WORKERS• FLOOD ZONE q.L.U.C.
r W CO.NPENSA1'ION INSURANCE PLG.CONTR. LIC.No. PLG, v N v
L z (This section need not be completed if the peri( is for one TOTAL N
hundred dollars(S100)or less.)
U O 1 certify that in the performance Of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
1.L F mit is issued I shall not employ any Person in any manner so as to
U W become subject to the Workers'Compensation Laws of California.
C. Date-Applicant ALTER OR ADD TO MECH. 5.00 BUILDING fTl
} W NOTICE: TO APPLICANT: If,after making this Certificate of I:,-
F_ Z emotion,you should become subject to dile Workers'Compensation APPLIANCE 5.00 PLAN CHECK 3
provisions of the Labor Code, you mus( forthwith comply with
U such provisions or this Permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 FEE d
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE fZJ
i
I hereby affirm that there is r hick this p lending agency(Sec.
EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this Permit is issued(Sec. MICROFILM
30 . HEATING UNIT(70 100,000 B.T.U.) 6.00
Lender'snder's Name e HEATING UNIT(OVER 100,000 B.T.U.)Lender's Address ELECTRIC
I certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
• information is correct I agree to comply with all city and county PLUMBING
orinanms dand state laws raloorg to buildi
ng construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby amh...Do representatives of this city to enter upon the BOILER-COMP IOver 100,000 BTU)SEE FEESCH. MECHANICAL
above-mention I Property for inspection purposes.
(We) agre to save, indemnify and keep hurinless' the City of MISC.- REFER TO ORD.
Cupertino 'litie I expen es which PERMIT ISSUANCE 10.00 CONST.TAX
Shay a way accrue . test said City nth. of the
rlwRuu MECH.CONT. LIG NO. MECH.
TOTAL TOTAL
SigoliftheofApP cab /Contractor Date �..�
INSPECTOR COPY
I