C8135 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS '
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
7
8135
OwNER'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
C N C P PHONE_ C -I� S(
CONTRACTOR
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
_ 'No LIGHTING FIXTURES 10.00/1.00
rorvTRAcroR's 'v PPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.No.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION
ADDRESS , SPECIALCIRCUIT 5.00'
ZIP TEMP.METER OR POLE INS. 20.00.
APPLICANT'$
ADDRESS
APPLICANT
MOTORS SEE FEE SCH.
SERV.POLECHANGE 20.00f/
w o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
v V. 1 hereby offnn Him I am littmsed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H D z' Professions Code,and my license is in full force and effect. ❑ ❑ ❑ ❑
Z o - License Class Lic.Number e{
Q Z Dutc Contractor
r BUILDING PERMIT
Irw o OWNER-BUILDER DECLARA'r O\ INFORMATION d
Aoa MISC.- REFER TO ORD
w 3 u r 1 hereby affirm that I am exempt from the Contractor's License•.. VALUATION $/FT.
Fu04 Law for the following reason.(Sec.7031.5.Iiuzinessand Prol'essinns -PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter.
2
in
¢ 20 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
O u requires the applicant for such permit to file a signed statement that TOTAL' -• PERMIT TO
A w es he is licensed pursuant to the provisions of the Contractor's License
F Z r
Law(Chapter 9(commencing with Section 7000)of Division 3 of the A
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE �/ t l>T I I
pro the basis for the alleged exemption.Any violation of Section 7031.5 -STORIES 'TYPE CONSTR.
n ;`0 by any applicant for a permit subjects the upplicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five.lmndred dollms(8500).):
O 1,as owner of the property,or my employeeswith wages as BACK F LOW PROTECT.DEV ICE 4.00 OCG GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for .sale(See 7044, 13 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 docs such work FIXTURES-PER TRAP 5.00 So.FT.FLOOR AREA TOTAL ACREAGE
himself or through his awn employees,provided that such improve-
mentsarenOl intended Or offered for sale If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is Sold within one year of completion.the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving that he did neat build or im-
pr ve or purpott of sale.). RES IND CON PB Other
as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 ❑i ❑ ❑ ❑ ❑
tic s 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 Lou 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
In,Cmuructar's License Law. TRACT NO. PARCEL NO.
❑ I annexe LOVE under Sec. I B.&P.C.for this WATER HEATER W/VENT 6.00
reason
X OwnerD:ae -�� ' WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DIi ARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure. ZONING
or a certificate of Workers'Compensation Insumnec,nr a certified ENG.SITE NO.
copy thereof(Sec.3800,Lab.CA
Policy No. Company
Q ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is fled with the city inspection division.
0 Applicant MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
i w CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOOZONE A.L.V.C.
LU > CONIPIMATION INSURANCE PLG.CONTR. LIC.NO. PLG.
Z CThis section need lot he mnhplcted it the permit is for one TOTAL V❑ N❑ V E] N❑
hundred dollars IS 100)or less.)
U 0 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H nut is issued, I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of-California.
y Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING /'.{�
} 0 NOTICE.TO APPLICANT: If,after making this Certificate of E.- _
f- z emption,you should become subject to the Workers'Compensut ion APPLIANCE 5.00 PLAN CHECK
provisions Of the Labor Code, you must forthwith comply with FEE `
U such provisions or this permit Shall be decried revoked. AIR HANDLING UNIT(TO 10=C-F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,0900EM.) 6.00 SEISMIC FEE S�
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the 3097,performance
MICROFILM
Cance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9,50 ELECTRIC •�{
I certify that I have rad this application and state that the
county VENTILATION FAN (SINGLE) 4.00
® information n correct.l 1 agree to comply with all city and county PLUMBING
ordinances and start lows 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 (Ove1100,000 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,judgnhnus, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any ay accrue against sa'd iIy in consequence of the
gra r g of this permit MECH.CONT. LIC.NO. MECH
..
AM L 04 .
TOTAL TOTAL -70
'Signature of Applicant Co tractor Date S N--••
INSPECTOR COPY