C8574 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENT[FI CATIONPERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS Q� / GQn� Q[
BUILDING - ELECTRICAL-PLUMBING-MECHANICA 85
OWN[ S PLAN CHECK VALIDATION
NAME
• ,( ne K4-,eAa /vK QTY. ELECTRIC PERMIT FEE
S• '�C�ir.� C PHONE
NOMERACToas UTLETS-SWITCHES-RECEP- 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
4f
R
ADDRESS
APPLIANCES-RESIDENTIAL 4.00
I/1/ty HONE L / PANELS 16.00 DATE OF APPLICATION
AVrtECT i
OR PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER -
LIC,NO SIGNS TRANS. 3.00
ADDRESS OR - SPECIAL CIRCUIT 5,06 PERMIT VALIDATION
, c#�pa l f0�2
jnp EMP.METER OR POLE INS. 20.00
ADDRESS rs MOTORS SEE FEE SCH. 1-7
1ADDRESS {.`' I
SERVICE CHANGE 20.00
to o o LICENSED CONTRACTORS DCC LARAfION TEMP.POLE 30.00
a v 1 herchy uflinn that I am licensed under provisions of Chapter 9 ISSUANCE DATE
a
� w (connnencing with Section 70001 of Division 3 of the Business and
t, a vi BLO ELECT. PLG. MECH.
H y z Professions Codc,and my license is in Hd furca unA effect. ❑ ❑ ❑
0 o m - [);lie echos Con Num her
9 y Dale Contractor
a r E I I BUILDING PERMIT
orrt ¢ OWNER-BUILDER DECLARATION
o to U MISC.- REFER TO ORD INFORMATION
w3 LL H I hereby affirm that 1 ain exempt from the Contractors License VALUATION $/FT.
e- o a Law for the following reason.(Sec 7031.5.Business and Professions PERMIT ISSUANCE 10.00
fes'>f Code:Any city or county which requires aperm it to construcLallee
¢ ¢ ¢ O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIG NO. ELEC.
S.
requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w m w he is licensed pursuant to the provisions of the Contractor's License
HiQ
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
i O Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE MA H
¢ H e the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
w. 5,: by any applicant for a permit subjects lite applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of nut Inure than five hundred dollars 155001.1:
❑ 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 One work,and the sl n¢turu is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:'I'hc Contractor's License Low dons not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SO.IT.FLOOR AREA TOTAL ACREAGE
himseltor through his own employees,provided that such• improve-
menu are not intended or offered for sale.If,however,the budding 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
builder will have the burden of proving that he did not huild or m- GAS USE
prove for purposeolsalcJ. INDUSTRIAL WASTE INTER. 30.00 IND CON PB other
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed 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 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 contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under See. ,B.&P.C.for this WATER HEATER W/VENT 6.00
coalor
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COM PENSA'r[ON DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of amsen ns
t to Self-insure,or or a certificate of Workers'Compensation ]nsurance,or a certified ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No. Company-+!A
0 ❑ Certified copy is hereby furnishedFIRE SPRINK ENERGY T 24
A
Z Z Cu;'
copy is filed with the city inspection division.
Y N Y
HO pR1MISC.- REFER TO ORD. ❑ ❑ [:] N❑
ncapt
it CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
L J COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG, Y❑ N❑ v E] N❑
CIL0 (This section need not be completed if the permit is for one TOTAL
hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I Shall not employ any person in any manner ur as to
O beconiesubject to the Workers'Compensat ion Laws of California.
ma Date- Applicant ALTER OR ADD TO MECH. 5.00 BUILDINGacz
} to NONCE "10 APPLICANT: If,after nwking this Certificate of Ex-
Z enquire,you should become subject to the Worker,'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, You must forthwith connply with FEE
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 4.00
CONST RUCTION LENDING AGENCY, AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE U
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the perf...move of the work for which this per...it is issued(Sec MICROFILM
3097,Civ.C.L / HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name- :SSQO� T44a 9s2.�. iii HEATING UNIT(OVER 100,000B.T.U.)9.50
Lender's AJdress ���� ELECTRIC
I certify that I ave read this applicatiAn an sta c h tS Ski•vbove VENTILATION FAN (SINGLE) 4,00
• it tonnation is correct. 1 agree to comply with all city and county BOILER H.P.or 100,0008.T.U.1 6.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this cityto cn ter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harndess the City of. MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs 4111, expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
gran it,,,of this pencil. MECH.CONT. LIC.N0.
TMOETCAHL.
TOTAL
Sit ro&�pra�antmsy o lsdloF "De
INSPECTOR COPY