8198 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
B ILOING APPLICATION & PERMIT
ACIDNESS
UILDING -ELECTRICAL-PLUMBING-MECHANICAL 1+
- -V_
ry N / PLAN CHECK VALIDATION
. 1. NAMEL CITY. ELECTRIC PERMIT FEE r
PHONE
ON TRACT 'S ~
NAME OUTLETS-SWITCHES-RECEP 115. 1.00
M1� ✓ _ = uC.No. e LIGHTING FIXTURES 10 1.00
APPLIANCES-RESIDENTIAL 4.00 '
ADDRESS
7 ��� tet. p,NONE - %� PANELS iQQQ DATE OF APPLICATION
/ R NITS _ / PLAN CHECK FEE P.C.NO.
OF PANELS (OVER 200 AMPI 20.00 Y
ENGINEER 1
LIC,NO, SIGNS TRANS. 3.00
noxa Ess ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP rrEMP. METER OR POLE INS. 20.00
ADDRESS MOTORS SEE FEE SCH.
ADDRESS 1
SERVICE CHANGE 20.00
0 o o LICENSED CONTRACTORS DECLARATION TEMP. POLE 30.00 '
¢ u v I hereby affirm ltmt I am lie..Scd under provisions of Chaptc,9 ISSUANCE DATE
< w (commencing with Section 7000)of Division 3 of the Business and
BLDG. ELECT. PLG. MECH.
Z H w Z Professions Code,and my Ilceme,is in full force and effect. - ❑
0 1,r License Class Lia Number?//z.(�,r��� D El
o z Fio Da[c Contractor
a Y s
BUILDING PERMIT
¢ ¢o a OWNFR-BUILDER DECLARATION INFORMATION
w g LL _ I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
VALUATION $/FT.
H u O`� Law for the following reason.(Sec.703 E,5,Business end Professions PERMIT ISSUANCE /10
Code:Any city or county which requires a permit to Construct,alter,
¢ ¢ Q ts improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
U_
.requires the applicant for such permit to file a signed sUdemenl that TOTAL PERMIT TO
n w mhe is licensed pursuant to the provisions of the Contractor's license
HZ
Law Section 7000)ofDivision 3 of the
Q
4 D Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ f o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
n 3 °�' 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($500).):
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEV ICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the st nreture 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 TOTALACREAGE
• Bents are not
hde ownnemred for sale.
if,
ed lowever,the
improve- GAS-EA.SYSTEM-11NC.4 OUTLETS 6.00
mems are not intended or thin on Cor sale.If,however,[he building -
or improvement is sold within one year hcompletion,the owner- GAS EASYSTEM-OVER 4 (EA) 200
builder will have the burden of proving that
t he did not build or a.,- - . . .
_ BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 a Ej IND go O Other
❑I ,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Ser. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSOR PARCEL NO.
and Professions Code:The Contractors License Law does not apply
to an owner ofproperly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with it contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ I am exempt made,See ,B.&PCforIli, WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACG FILE N0.
WORKERS'COMPENSATION UHCLARA1AON WATER TREATING EQUIP. 5.00
I hereby affirm 0wt I have a certificate of consent to ,If insum.
y� or a certificate of,Workers'Compensation Insurance,or a certified 'ZONtNG ENG,SITE N0.
ropy thereof(Sce.3800,Lab.C.,
Policy No. Company »O i i N
Q,,,kbrtified copy is hereby fur shed FIRE SPRINK ENERGY T34
FZ-' z ❑ Certifiedcgpy i5.,fifC,)i h ✓city inspection division. MISC.- REFER TO ORD. � � E]
O Applicant /� (�/ Ol e Y N V N
!r N CIiRTI FICA FF Of 1 EMPTION hRKGRS• PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTR. ❑c.NO. PLG.
0- Z This section need not be completed if the permit is for one TOTAL V N� Y F] N[]
hundred dollars($100)or less.)
U O 1 Fenny that in the pert urmance of the work fi,which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any person in any manner so as to
U becomesubject to the Worked Compensation Lawsof California.
a Dare Applicant BUILDING
>_ ED NOTICE. TO APPLICANT: If,after making this Certificate Of Ex- ALTER OR ADD TO MECH. 5.00
F 2 emption,you should become subject to the Workers Compensation APPLIANCE 5.00 - PLAN CHECK
provisions of the Labor Cade, you must forthwith comply with FEE
U such provisions or thm
is permit shall be deeed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I1B)000CEM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that l have read this application and smte that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agece 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 BTUI 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 an way accrue a, 'nst said City in consequence of the
granting of nor. MECH.CONE, LIG NO. MECH.
TOTAL TOTAL
nPebf tr3tC e ��,
INSPECTOR COPY