8669 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
!
BUILDING �OL APPLICATION & PERMIT �^^^
�/ BUILDiN b b y
BUILDING -ELECTRICAL-PLUMBING -MECHANICAL
OWNER'S - -
'NAME PLAN CHECK VALIDATION
• QTY. ELECTRIC PERMIT FEE
r PHON
NAMErIACTOR S OUTLETS-SWITCHES-RECEP 10.00/1.00
�-A o LIC.No, LIGHTING FIXTURES 10.00/1.00
C NTRACTOR'S
ADDRESS o [J PPLIANCES'-RESIDENTIAL 4.00
PHONEY66- SAf PANELS 10.00 DATE OF APPLICATION
.OR L PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER - - -
i LIC NO, SIGNS TRANS. 3,00
ADDRESS ENG, SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS. 20.00
CANT APPLINT'S
ADDRESS MOTORS SEE FEE SCH. / / /�f/J�
SERVICE CHANGE 20.00
o
LICENSED CONTRACTORS DECLARAT �'
ION TEMP.POLE 30.00 ,/
a o� I Imlcby affirin that 1 at,Iicen Ned under provisions of Chapter 9 ISSUANCE DATE
In C w (commencing with Section'7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H/N z Professions Code,and my license is in full force and effect ❑ [Iz o w - Licenses Class�/� Lie.Nu in
o ? t- Dale O - )�_Comlruc r
a m M 4 BU LD NG ERMIT
¢ ¢ w ¢ )WAIER-BUILDER-R Dai+ �-
a o: u MISC.- REFER TO ORD INFORMATION
X g LL y 1 hereby affirm that 1 um exempt 1'r .5 the Contractor's License
u
Car Law for the following reason.(Sec.7031.5.Business and Professions VALUATION $/FT.
- PERMIT ISSUANCE 10.00
Code:Any city of.,county which requires a permit ro construct,,also
re Q ¢ p improve,demolish,cn repair any s(rueture,prior to its issuance,also ELEG CONTR. LIC.NO, ELEC.
ro ar ¢ requires the applicant fur such permit to file a signed statement that TOTAL
u w he is licensed ursuunl lu the PEFMITIO
p provisions of the Ccnnarloh License '�Y�( PER
Hza BusifChand Professions
lh Section 7s exemttheroa3ofthe
re E O Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ H w- the basis for the alleged exemption.Any violation t ofSeclion7031.5 enaly STORIES TYPE CONSTR,
n ; _ by any applicant for aPermit 1ddoledsthe epplicam roacivil penahy ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred property,
s Imy lro7: r - - -
O I,as owner of the property,or my employeeswith wagesuv BACK FLOW PROTECTDEVICE 400
inter sole compensation,will Ole work,and the is not . .
OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business andnd Professions essions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law docs not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himselfor through his own employees.provided that such improve-
mcitsam net intended or offered for sales If,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 8.00
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 build or im- BUILDING USE
prove for purpose of sale.). IND WASTE INTER. 30.00 I❑ ❑N EPB l El L
❑ 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 1 ASSESSORS PARCEL NO.
and Professions Code:'file 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. SEWE R-SANITARY-STO RM EA.2001t/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec..,B.&P.C.for this
reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE No.
WORKERS'COMPENSA'I'ION DECLARA'T'ION WATER TREATING EQUIP. 5.00
I 1 hereby affirm that I have a certificate of consent to self-insure, r
or a celtiflcale of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec,3800,Lab.C.Y ,L
Policy Nn, Company
O ❑ Certified<oIIA is hereby f flluJl ed.
Z Z "Cd pyduh the city lspedion division. FIRE SPRINK ENERGY RZ4
Fp Applic' I _- MISC.- REFER TO ORD, YE] N� Y ❑ NE]
� N 40 ICP Ili O F BX Mill ON'FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.c.
W COMI'fiN5ATION INSURANCEPLG.CONTR. LIC.NO.
d O PLG.
= Z (This section need nal be comp ctctl it the Perrot is for nor TOTAL V N V N EJ
� O handled dollars(5l00)or Ices.) ,
I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mil is issued,1 shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
0 IL Dec Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
�- 0 NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F Z emptlon,you should become object m me Worker,'Cumpensalion APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10)000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.F.M.) 6.00 SEISMIC FEE
-I hereby affirm that (here is a construction lending agency far EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work far which this permit is issued(Sec. MICROFILM
3097,Civ.C.). H EATING UN IT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lenders Address HEATING UNIT(OVER 100,000 B.T.U.)8.50 ELECTRIC
I certify that 1 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 stale haws relating to building construction, and BOILER-COMP(3 H.P.or 100,000B.T.U.) 6.00
hereby authorize representatives natives ec this city es error upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property forinsp of this
purposes.
(We) agree to Save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against IiabiliticsNudgments, costs and expenses which CONST.TAX
VinanyRway accrue Inst said City'in consequence of the PERMIT ISSUANCE 10.00s per MECH.CONT. LIC.NO. MECH.
TOTALTOTAL
pp cant/C-ntract Dat
L� _-�„ INSPECTOR COPY
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