C8703APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON
APPLICATION & PERMIT
BUILDING - ELECTRICAL -PLUMBING - MECHANICAL
PERM IT NUMBER
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NAME
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PHONE-
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
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LIGHTING FIXTURES 00
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CONTRACTOR'S
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APPLIANCES -RESIDENTIAL �--4.00
PANELS O
PHONE
DATE OF APPLICATION
ARCHITECT -
OR
ENGINEER
LIC. NO
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
OR ENG.
A
ADDRESS
SPECIAL CIRCUIT 5.00
IORCH,
PE I$ ATION
EMP. METER OR POLE INS. 20.00
ZIP
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-
JUN O U 19
!� 85
APPLICANTS
ADDRESS
MOTORS SEE FEESCH.
SERVICE CHANGE 20.00
OJ
City of Cupertino
LICENSED CONTRACTORS DECLARATION
TEMP. POLE 30.00
1 hereby affirm that I am licensed under provisions of Chapter 9
(Commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect
License ClassLic. Number
ISSUANCE DATE
BLD ELECT. PLG. MECH.
❑ ❑ ❑
Date Contractor
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason. (Sec. 703 1.5, Business and Professions
Code: Any city or county which requiresa permit toconstruct, alter,
BUILDING PERMIT
INFORMATION
MISC. - REFER TOFRD
PERMIT ISSUANCE 10.00
VA DATION $/FT.
ELEC. CONTR. LIC. NO.
ELEC.TOTA 7-
improve, demolish, or repair any structure. prior to its issuance, also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of t he Contractor's License
Law (Chapter 9 (commencing' with Section 7000) of Division 3 of the
/ -
PER O
Business and Professions Code) or that he is exempt therefrom and
QTY. PLUMBING PERMIT FEE
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant fora permit subjectstlic ton civil penally
of not more than five hundred dollars ($500).):
5500 ).):
❑ 1, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
STORIES
TYPE CONSTR.
�
ALTER-DRAIN-WATER(EA) 500
. .
BACK FLOW PROTECT. DEVICE 4.00
OCG GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA,COND. 5.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law docs not apply to an owner of
FIXTURES - PER TRAP 5.00
GAS - EA. SYSTEM - 1 1 NC. 4 OUTLETS 6.00
SO, FT. FLOOR AREA
TOTAL ACREAGE
'
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such, improve
ments are not intended or offered for sale. If, however, the building
or improvement is sold within one year of completion, the owner
unlace- will have the harden of proving that he did not build or int.
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
a IN USE
ove for purpose of sale.).
I, as owner of the property, am exclusively cmumcling with
RES IND C PB Other
❑ ❑ , ❑ ❑
INDUSTRIAL WASTE INTER. 30.0 U,
lic contractors to construct the project (Sec. 7044, Business
and rofessions Code: The Contractor's License Law does riot apply
to a owner of property who builds or improves thereon, and who
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESS 5 RCELNO.
contracts forSuch projects with a contractonO licensed pursuant to
fire Contractors License Law.
Awl xem tunder.ec. ,Ii.&P.C. for this
rcasom
SEWER -SANITARY -STORM EA. 200ft110.00
TRACT NO,
PARCEL NO,
WATER HEATER W/VENT 6.00
Owner '7 i Du rE`cB--�
WATER SYSTEM 5.00
ACC.DATE
ACG FILE NO.
woR RIiRS'COMPI'Yf1 NDFCLARAI'ION
WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have o cerlific:Oe or consent to sclfsinsure.
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof (Sec. 3800, Lab.O.).
Policy No. Company
.
❑'Certified copy is hereby furnished.
❑ Certified copy is filed with the city inspection division.
Applicant
FIRE SPRINK
Y ❑ IN
ENERGY T 94
Y ❑ N❑
MISC.- REFER TO ORD. .
CERTI FWAI E OF li xliMl'l' ION PROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.U.C.
COMPFNSAI'ION INSURANCE
.(This section need not be completed if the perntil is for one
❑ N ❑
Y ❑ N ❑
PLG. CONTE. LIC. NO.
PLG.
TOTAL
hundred dollars IS 100) or less. )
I certify that in the perl'urmancc of ale work for which this per-
mil is issued, 1 shall not employ any person in any manner so as to
QTY MECHANICAL PERMIT FEE
FEE SUMMARY
become subject to the Workers' Compensation Laws of California.
ALTER OR ADD TO MECH. 5.00
Dale -Applicant
BUILDING
NO] ICI' If, after making this Certificate of Ex-
APPLIANCE 500
.
AIR HANDLING UNIT (TO 10,000GF.M.) 4.00
PLAN CHECK
FEE
emption, you should become subject In the Workeri Commensal ion
you shout become
provisions tire u with comply with
e Labor Code, you must forth
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec.
3097. Civ.C.L
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address
HEATING UNIT (OVER 100,000 B.T.U.)9.50�
ELECTRIC
GLE'
VENTILATION FAN (SINGLE) 4.00
I certify that I have read this application and state that the above
information is correct. 1 agree m comply with all city and county
ordinances and slate laws relating to building construction, and
PLUMBING
^
G
_
BOILER-COMP(3 H.P. or l B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
(We) agree to save, indemnify and keep harmless the City of
MISC. - REFER TO ORD.
Cupertino against liabilities, judgments, costs and expenses which '
may in any ay accrue- unrest s City in consequence of the
granting f this pInni .
PERMIT ISSUANCE 10.00
CONST. TAX
MECH. CONT. LIC. NO. MECH.
TOTAL /
TOTAL
Signa re lican ntmc[ r Date
INSPECTOR COPY