C8560 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
X AooREss 8- 0
o Ld l�017� Doti.. BUILDING-ELECTRICAL-PLUMBING-MECHANICAL T4S !l!t
\ OWNER'S �C� PLAN CHECK VALIDATION
'v\ NAME QTY, ELECTRIC PERMIT FEE
loxMP-4 r 1zS. r�CTEZso1��DNE
v NomERAc*oRs UTLETS-SWITCHES-RECEP 10.00/1.00
Q�L.a4S REFmooat-,�% LIGHTING FIXTURES 10.00/1.00
CONTRACTOR. I'ar APPLIANCES-RESIDENTIAL 4.00
ADDRESS
/ 1
JN PHONE I PANELS 10.00 DATE OF APPLICATION
ARCH ECT
OR ECKFEE P
PANELS IOVER 200 AMP) 20,00 PLAN CH .C.NO.
ENGINEER
ua NO SIGNS TRANS. 3.00
ARCH.ADDROR ENG. SPECIAL CIRCUIT S.QQ PER MIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
ADDRESS r
ASS MOTORS SEE FEE SCH. J
OR
ISERVICECHANGE 20.00
t w o o LICENSED CONTRACTORS DECLARATION' TEMP.POLE 30.00
¢u u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
4 w (commencing with Section 7000)of Division 3 of the Business and
4 A BL ELECT. PLG. MECH.
r y i Professions Code,and my license is in full force and uRcd. G
z o y - License Class g'I Lic Number ❑
.o r a / Data ---Lo � Contractor
a m 2 , - �� O 8 LDING PERMIT
¢ ¢ 4 OWNER-BUILDER DECLARATION '
�a ow.° MISC.- REFER TO ORD INFORMATION
w 3 N 1 hereby affirm that I am exempt from the Contractor's License
t VALUATION SIFT.
-F a-
0 J Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00
my Code:Any cityor county which requiresapermit toconstruct.alter,
¢ ¢ 4 2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. A
a wo u requires the applicant for such permit to file a signed statement that TOTAL ,pEHMIT TO
m he is licensed pursuant to the provisions of the Contractor's License
- � za
Last(Chapter 9(commencing with Section 7000)of Division 3 oftle e'
1usiness and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ F 0 the basis for the alleged exemption.Any violation of Section 7031.5 I STORIES TYPE GEPNSTHI
n 3 § by any applicant for a pernot subjects the applicannoa civil penalty
-. o1not more than five hundred dollars($500).): ALTER-DRAIN& VENT-WATER (EA.) 5.00 '
❑ I.as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCG 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
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 ACREAGE
• himcents arem notself through his own employees,provided that such improve-
intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the wner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 t
builder will have tire burden of proving that he did not build oar int- -BUILDING USE
ruse for purpose of sale.).' INDUSTRIAL WASTE INTER. 30.00 RES IND CDN PS Dmer
❑ I,as owner of the property,am exclusively comma ing with ❑. ❑ ❑ ❑
licensed contractors to construct the project ISec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code"rBc COmlracIor's License Law does Bat apply LAWN SPRINKLERS-OVER 5 IEA.) 1.00 pTt
_ \
to an owner of property'who builds or improves thereon,and who
contracts for such projects with a contractotfs)licensed pursuant to SEWER-SANITARY-STORM EA.2001t/10.00
the Contractors License,law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner - Date WATER SYSTEM 5.00
+.um ACC.DATE ACC.FILE NO.
" WORKERS'CONI PENSATION DL'CLARA'I'ION IWATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to Adl-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lrb.C.).
71 Policy NO ,t-NF!�•y' 'T�s\n.IGAMGJs/D
O ❑ Ce -led cop of Ey'OuIncl u, FIRESPRINK ENERGY T-24
Z 2 ❑ Certifiedopy isA filed with the city inspection division. MISC.- REFER TO ORD. �,
O ApplicantTI Q.rM vv� �-L� Y ❑ N❑ Y ❑ N❑
rr y -1 PERMIT ISSUANCE 10.00
LU - CERTIEIGONIPE PK6NIPT ION FROM WORKERS' FL0o0 ZONE A.L.U.C.
W > COMI'IiNSA'TION INSURANCE, PLG.CONTR. LIC.N0. PLG.
0.Z CI his section need not he completed if the permit is for one " TOTAL Y❑ N❑ Y❑ N❑
hundmddollurs(S100)orlcss.) -
U O 1 certify that in tine performance of the work for which this per-, QTY. MECHANICAL PERMIT 0.FEE FEE SUMMARY
W H mit is issued,I shall not employ any person in any manner so as toy
U become subject to the Workers'Compensation Laws of California. 4
UJ Dec Applicant ALTER OR ADD TO MECH. 5 BUILDING /
} N NO'I"ICE TO APPLICANT: If,after making this Certificate of Ez-
(_-? ensption,you should become subject to the Workers'Compensation APPLIANCE ,/� 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply withFEE
CJ such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1Q000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the red..manec of the work tin which this peon it is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lenders Name
Lender'.,AddreHEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
ss
I certify that correct.
read this application ith.11 city
at'It'.above VENTILATION FAN (SINGLE) 4.00
• information n 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 100,0006.T.U.) 6.00
hereby' authorize representatives of this city b enter upon the g01 LER-COMP(Over looxO 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 and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in ttmsequcnce of the
grandn of this emhlt. , MECH.CONT. LIC.NO. MECH.
.
\X o TOTAL TOTAL
SIk a r f r o f do ulc
INSPECTOR COPY -