C8455 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
\, BUILDING PROJECT lDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT °
y ADDRESS - - / I� �'
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL M5
/ OW P'
NAME / „`-PLAN CHECK VALIDATION
QTY. ELECTRIC PERMIT FEE
NONE
COI"NT Ac Rs UTLETS-SWITCHES-RECEP 10.00/1.00
e4�,NO. 7 LIGHTING FIXTURES 10.00/1.00
ADDRESS s tr APPLIANCES-RESIDENTIAL 4.00
ONE _ PANELS 10.00 DATE OF APPLICATION
ORR E PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.O.NO.
ENGINEER
LIC.No. -SIGNS TRANS. 3.00
ADDRESS END, SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 `
APPLICANTSMOTORS SEE FEE SCH. J r
ADDRESS
ADDR
- SERVICE CHANGE 20.00 i
.woo LICENSED CONPRACTORS DECLARATION TEMP.POLE 30.00
G u U I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
h a e. (cennmu'ncing with Suction 7000)of Division 3 of life Business and BLDG. ELECT. PLG. MECH.
H w Z Professions Code,and my license is in full three and effect.
z o w - License CI ss hie.M1'unlher 7� ❑ ❑ ❑
9 z r Date Contractor
a Y f BUILDING PERMIT
rc a w a OWNER-BUILDER DECLARATION RATION
A O a INFORMATION
wg LL _ I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
.. o j Law for the following reason.(Sea 703 1,5,Business and Professions VALUATION g/FT.
'I- - PERMIT ISSUANCE 10.00
Code:Any city or counly which re-quirus a permit la construct,alter,
Q ¢Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. L �(
O ¢ requires tire applicant for such permit to file a signed statement that TOTAL
u w er u he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
H he i Law(Chapter 9(commencing with Section 7000)o'Division 3 of the iyNsu� !Js
r{
F 4 o Business and professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE /Y T--/
a F o lite basis for the alleged exemption.Any violation of Section 7031,5 STORIES TYPE CONSTR.
wc2 hyanyapplicntfor a permit subjects the applicant to a civil penally ALTER-DRAIN -WATER (EA.) 5.00
of not turn,than live hundred dollars(55001,):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC. RES.urvtTs
their sole compensation,will do the work,and the structure is nal
intended or offered for sale (Sea 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does riot apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP / 5.00 SQ.ET.FLooe AREA rorAL ACREAGE
himself re of rote his own employers,pnrvt.ho that such improve-
or improvement
are not intended or offered for sales If,mpleveq 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 IEA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ 1,as owner of the property,am exclusively'contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to con,vtruct the project fSec. 7044,Business LAWN SPRINKLERS- 1 INC'5 V.B. 6.00 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
contracts for such projects with a contmctortsl licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. .PARCEL NO.
❑ lam exempt under Sec ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO,
WORK ERS'COM PENSATION DECLARATION WATER TREATING EQUIP. "'--'�" 5.00
I hereby affirm that I have a certificate of consent to scll�insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thercof(Sce.3800,Lab.C.).
Policy No. Company
❑ Cyyitified copy is hereby fur Vshed.
z Z k7iC'erll copy is life d I lI the 'ity inspection division. FIRE SPRINK ENERGY T-YO
/ MISC.- REFER TO ORD. N Y N
O[ Apphc;tm- V ❑ ❑ ❑ ❑
CC rn CERTIFICATE OP EXEMPTION Oh WORKERS• PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.UC.
W J COhIPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
O (This section need not be completed if the permil is for one TOTAL Y❑ N[:] V❑ N❑
Z hundred dollar,($100)...less.)
L) O I ecrtily that in the perlbnnance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
1L )- mil is issued,I shall not employ any person in any manner so as to
QU become subject to the Workers'Compensation Laws of California.
ED
Q. Date Applicant BUILDING
} to NOTICE TO APPLICANT': If,after making ITS Certificate of Ex- ALTER OR ADD TO MECH. 5.00
f- ? eruption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE 02
C..) such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 3
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L I H EATING UN IT ITO 100,000 B.T.U.) 8.00
Lender,Name HEATING UN IT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
1 ecrtily that I have read this application and ,are that the above VENTILATION FAN (SINGLE) 4,00
infor Talion is correct.1 agree to comply with all city and countyPLUMBING
ordinances and stale 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
above-mentioned property for inspection purposes. BOILER-COMP(Over 700,000870)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 PERMIT ISSUANCE 10.00 CONST.TAX
may in any way ac<r against said City in consequence f the
t ing of this permit MECH.CONT. UC.NO. MECH.
TOTAL TOTAL
of /. c r ale
INSPECTOR COPY