C8653 APPLICANT TO FILL•.IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFI CATION PERMIT NUMBER
BUILDING - APPLICATION & PERMIT
ADDRI s
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
6653
Is ME E - PLAN CHECK VALIDATION
NAME 1^AN tl ANSDA QTY. ELECTRIC PERMIT FEE
� .� �o%VS J' q#i b-o76 Z/35 „Q 0,1, el, _
N°AMERACTORs �o l�'.� OUTLETS-SWITCHES-RECEP 10.00/1.00 (j'
% S Ic.No. LIGHTING FIXTURES 10.00/1.00
CONTRACTORSPPLIANCES-RESIDENTIAL 4.00
? ADDRESS �7/1 n
p c�,+o9 /1 WDCS 231HPANELS 10.00 DATE OF APPLICATION
RRPLAN CHECK FEE
ARCHITECT PANEL (OVER 200 AMP) 20.00
OR
ENGINEER
Sec,NO. SIGNS BANS. 3.00
ADDRESS ENG. CIRCUIT 5.00 S PERMIT VALIDATION
zlv fTEMP.METER OR POLE INS. 20.00
AMOTORS , SEE FEE SCH. J
DRESS E55
ADDR
SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DI?CLIRATION TEMP.POLE 30.00or
a i w 1 hereby affirm that I am licensed under provisions of Chapter 9 ]� ISSUANCE DATE
y a y (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
w z Professions C ly license is in full fop.' f1c
z O m - License Class Con Numb .,
4 w H o/ Dute Conlraeto u
a a V BUILDING PERMIT '
¢ a N: - UILDER DECLARATION
a o a UINFORMATION
w 3 LL I- 1 hereby afllrm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u 0¢ Law for the following reason.(Sec.7031.5.Businessand Professions pERMIT ISSUANCE 10.00 VALUATION $/FT.
� - 0 Code:Any city or county which requiresa permit toconstruct,alcr,
ELEC.CONTR. LIC.NO. Q
¢ ¢ 4 O improve,demolish,or repair any structure,Prior to its issuance,also ELEC. 7 Q�V
m u requires the applicant for Su
requires to tile a signed statement that TOTAL PERMIT TO
a w m he is licensed pursuant to the provisions of the Contractor's License
r z¢ Law(Chapter 9(commencing with Section 7000)ofDivision 3 of the y�
E o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE 1 00
¢ H o the basis for the alleged exemption.Any violation of Scclion 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit Subjects the applicant to a civil penally ALTER-DRAIN&VENT-WATER (EA.) 5.00
ss ofnotmo.e than five hundred doll ..(S500).):
❑ I,as owner at the property,or my cmployccs with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work.and the strmture is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Coatmcia,License Law docs not apply to an owner of
property wbo builds or improves Illecon,and who does such work FIXTURES-PER TRAP 5.00 SO.rT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided full such impnsve-
meatsarenotintendedoroffred
el'or sale.If,however,the build ing GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year atcompletion, the owner. GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving that hu did not build or in,. GAS USE
Prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 RES INDma,
CON PB O
ID1,as owner of tire property,mn exclusively contract,.ng with .. ❑ , El ❑ ❑
licensed contracrmn to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL N0.
and Professions Code:'I'he Contractor i License Law does not apply
to an owner of pronely who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractmis)licensed pursuant to gEWERSANITAR V-STORM EA.200ft/10.00
the Contractors L,.cense Law. TRACT NO. PARCEL NO.
❑ l am exempt under Sec. ,B.&P.C.fir.this WATER HEATER W(VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO' S."4
WORK FRS'COM PENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a cerEEcate of consent to self-insure.
or a cerGficute of Workers'Compensation Insurance,ora certified ZONING ENG.SITE NO.
7 copy the!o (Set.3800,�,alyCI. ,r � -4
/
Policy N (Irsp-I -nd/�I rO-4
❑ Cer d e s ere y m shed. 4 FIRE SPRINK ENERGY T 24
Z Z ❑ Certi(red Sopy is Ele ith Ore cit inspection Division.
Fpj- Appl;cam`y-._ c - MISC.- k REFER TO ORD. . n Y [J n[] v [D NE]
CCN: ' CERTIFICATE OP EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C.
LU J CO.MPF.NSATION'INSURANCE PLG.CONTR. LIC.NO. PLG. NEI
O (This Section need not be completed if the permit is for one TOTAL V N Y
2 hundreddo1lars(SI00)orless.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
IL H mit is issued,I shall not employ any person in any manner so as to
❑ become subject to the Workers'Compensation Laws of California.
a Date Applicant BUILDING
} to NOTICE: TO APPLICANT.Af,�aftcr making this Certificate of lis- ALTER ORA TO MECH. 5.00
F 2 emption,you should become subject to the Workers'Compensation APPLIANCE 5.060
0 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 JOSMC.F.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 r
the performance of the work lirt which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address IDEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC /
I certify font l have read thisapplication and state that Bre 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-COW(3H.P.or 100,000 B.T.U.) 6.00
hereby xutiored roperty tonics of this cry es enter upon tlIC BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
lientonl cnuoncd pmperytor;nspcf this
purposes'. /
(We) agree ID save, indenmify and keep harmless the City of MISC.-
Cupertino agar Ii abilities,judgments, costs and expenses wREFER TO ORD.hich PERMIT ISSUANCE ORD. CONST.TAX
may in an vay accrue against said L'yin ro ur,equenof tire10.00
graming Ihl •mit. MECH.CONT r LIC.NO. MECH.
TOTAL TOTAL 2
eta 1 qn rector Unt
INSPECTOR COPY