C8541 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT1DENTIFICATION PERMIT NUMBERBUILDING APPLICATION & PERMIT
ADDRESS
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 8541
O.N R !n� PLAN CHECK VALIDATION
NAME rfVpRey CITY. ELECTRIC PERMIT FEE
ONE
1 NAME 32G �p� UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO.
aooRELIGHTING FIXTURES 10.00/1.00
RE ss° PPLIANCES-RESIDENTIAL 4.00
/ �/r
\ PANELS 10.06 GATE OF APPLICATION �
OR
RCXIE PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.c.No.
ENGINEE
o. SIGNS TRANS. 3.00
ARCH.ORE PERMIT VALIDATION
/ ADDRESS �N rVq ) SPECIAL CIRCUIT 5.00
1 11 co r I Z v ZIP EMP. METER OR POLE INS. 20.00
APPLICANT'S
5 MOTORS SEE FEE SCH. 416ir a00RE55 � SERVICE CHANGE 20.00
o D LICENSED CONI'RAC'PORS DECLARATION TEMP. POLE 30.00
Fz ws s l hereby affinn that I am liconwd under provisions of Chapter 9 ISSUANCE DATE
< w , (commencing with Section 7000)of Division 3 of the Business and BLD . ELECT. PLG. MECH.
F w Professions ode,anA n1,license is in full forpy-and gffect. ❑ ❑ ❑
2 z u/e License Clns hie.Number/
2 . r DWc'v Contractor
A BUILDING PERMIT
¢ ¢o a OWNER-BUILDER DECLARATION INFORMATION
E:
0 LL r I hereby al'fino that 1 an,cxcnght Crom the Contractork License MISC.- REFER TO ORD
uoj Law for the followingo,vam.(Sce.7031.5,BusinL,,mdP,.G ,ons •PERMIT ISSUANCE 10.00 VALUATION $/FT.
�y Code:Any city orcounty whichrequiresapennit toconslract,alter,
Q ¢ ¢o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
M
LL requires the applicant for such period to file a signed statement that TOTAL PEP IT TO
d w se he is licensed pursuant to the provisions of the Contractor's License
F z a
Law(Chapter 9(commencingwith Section 7000)of Division 3 of the
Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE 6�0 All lo%sv re
¢ r$ the basis for the alleged exemption.Any violation of Section 7031.5 1 STORIES TYPE CONSTR.
n3 � by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(S500)):
❑ 1,as owner of the property,or my cmpluyces with wages as BACK F LOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sale 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 improvesthereon,and who does such work FIXTURES-PER TRAP 5.00 SO,FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees provided that such improve-
mems are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement Is Sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
proveforpurposeofsale.). INDUSTRIAL WASTE INTER. 30.00 REs IND CON PB Omer
❑ I,as owner of the property',um exclusively contracting with ❑ ❑ ❑ C1 ,4
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:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contrathe Contractor's
Licenscts Lwithammmdots)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO,
the tract for is License Law.
❑ Ium Lee ns pt under Ser.-,B,&P,C.for this WATER HEATER W/VENT 6.00
Owner Ume WATER SYSTEM 5.00 ACC.OATF ACC.FILE NO.
WORK HRS'COM PENSA KION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm Thal I have it mrlificote of ttn,ent to elf-insure, ZONING ENG.SITE NO.
or a certiGcale of Workers Compensation Insurance,or u certified
copy thereof(See.3800,La b.C.l.
Policy No. Company
❑ Cwil ied copy is 11 ereby furnished. FIRE SPRINK ENERGY T-24
Z pP '•rI'll"' 'o isl���liled witltillc city inspection Division. MISC.- REFER TO ORD. Y N y N
A I ' 1�jf ipp v.c•� ❑ ❑ ❑ ❑
y CIiRI'Il4CATli OI'IiXIiMP"I'ION PROM WORK ERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.LU.C.
LU > COhIPENSAIION INSURANCE PLG.CONTR. LIC.NO. PLG. ❑ N❑ V❑ N[3CL Z (Phis section need not be completed if the Permit is for one TOTAL y
hundred dollars IS 100)or less.)
U O 1 canify that in the performance Of the work for which this per- CITY MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued, I slmll not employ any person in any manner so as to ,
O w become subject to the Workers'Compensation Laws Of California.
a Dare Applicant ALTER OR ADD TO MECH. 5,00 BUILDING
>_ Do NOTIC17 TO APPLICANT: If,after making this Certificate of Ex-
H Z emotion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of [lie Labor Code, you must forthwith coply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 1OPMC.F.M.) 6.00 SEISMIC FEE
r I herebyaffirm that there is a construction lending K agency for EXHAUST HOOD(WITH DUCT) 5.00 -
30 performance of the work for which This permit is issued(Sec. MICROFILM
30ndL,'s ..... HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
- I certify that I 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 state laws 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 (Over 100,000 BTU)SEE FEESCH. MECHANICAL
above-mentioned properly for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgmmhts, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
ixemf this aarnut. MECH.CONT. LIC.NO. MECH.
_ TOTAL15A A TOTAL
r
Sig ature t5 t/6ontmctor Date
INSPECTOR COPY
1