8668 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
T' 7 0 WFyrACR Er �e BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 8658
OWNER'S J PLAN CHECK VALIDATION
"AME C QTY. ELECTRIC PERMIT FEE
- E.0 HDNE _z
v NAMERAcroRs UTLETS-SWITCHES-RECEP 10.00/1.00
-LIC.NO. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
ADDR Ess
PHONE PANELS 10,00 DATE OF APPLICATION
ORCHITECT PANELS (OVER 200 AMPI 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
Lac.NO. SIGNS TRANS. 3.00
ADDRESS END SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP EMP. METER OR POLE INS. 20.00
ADDRESSTs MOTORS tSEE FEE SCH.
SERVICE CHANGE 21 n0
00 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a mo u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUAN LE DATE
y z n (commencing with Section 7000)of Division 3 of the Rainless and
BLDG. ELECT. I PLG. MECH.
F D i Professions Code,and my license is in full force and effect. ❑ ❑ ❑
Z O w- License Class Lie.Number
o z - Our Date Contractor
a m s BUILDING PERMIT
0 u< OWNER-BUILDER DECLARATION INFORMATION
se g a y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
H u o J Law for the following reason.(Sea 7031.5,Business and Professions PERMIT ISSUANCE VALUATION $/FT.
Code:Any city or county which requires a permit to construct,alter, 1�0 -
s ¢ ¢ 2O improve,demolish,tit repair any structure,prior to its issuance,also ELEC.CONTE. LIG NO. ELEC.
n wO LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
e is licensed pursuant to the provisions of tiro Contractor's License
F z soLaw(Chapter9(commencing with Section 7000)of Division 3 ofthe
4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
Ic I- m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
A _ by any applicant for a permit subjects the applicant to a civil penalty
Of not more than five hundred dollars(SS00).): ALTER-DRAIN&VENT-WATER (EA.) 5.00
I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
IIX sole compensation,will do the work,and the structure
is lot OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of 1
property who builds or improves thereon,unit who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such'in
P'Ove-
mints are not intended or offered for sale.ll',however,the budding GAS-EA.SYSTEM-111NC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 (EA.) 200
builder will have the burden of proving that h - . - . .
e did not build or im- BUILDING USE
RES IND CON PR Other
prove 1,as owner
of sale.). - INDUSTRIAL WASTE INTER. 30.00 ❑ 0 ❑ ❑ ❑
❑ I,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS FARCE L 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 contractogs)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
Ilia Contractor's License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,BAP.0 for this WATER HEATER W/VENT 6.00
reason
\/ Owner Date WATER SYSTEM 5.00
w ACC.GATE ACC.FILE NO.
! WORK ERS' . hN' A N I ;C TIO WATER TREATING EQUIP. 5.00
I hereby alflrm that I have a Certificate of consent to sel Glnstlre, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(See.3800,Lab.C.).
Policy No. Company
Q ❑ CCI]ilied ropy is hereby l'umishcd. FIRE SPRINK ENERGY T 24
Z_ Z ❑ Cenilied copy is tried with the city inspection division. MISC.- REFER TO ORD.
Q Applicant Y E] NE] y ❑ NE]
H w
W PERMIT ISSUANCE 10.00
LU CER1'IFICA'I'Ii OF r xEldP'fION'FROM WORKERS' FLOODZONE A.L.UC.
COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
CL Z (This section need not be completed if tine permit is for one TOTAL Y N v N
EI
hundred dollars(S 100)or less.)
U O 1 certify that in the performance of the work for 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 It,
U become subject to the Workers'Compensalion Laws of California.
W Date Applicant BUILDING
)_ SO NOTICE TO APPLICANT: If,after making this Certificate of fix- ALTER OR ADD TO MECH. 5.00
F. Z enlption,you should become subject to the Workers'Compcnsatimn APPLIANCE 5.00 PLAN CHECK
Provisions of the Lobo. Code, you most forthwith comply with FEE
U 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.EM.) 6.00 SEISMIC FEE r
I hereby .]'firm 111.1 little is a Construction Icnding agency Por EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work lint which this permit is issued(Sec. MICROFILM
3097.Cie.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name H EATI N G U N IT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC d�
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 refuting to building construction, and BOILER-COMPO H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon tiro
abose 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 PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against Said Cit in consequence of the
gmntingo il. MECH.CONT. LIC.NO. MECH.
rTOTAL TOTAL
reol ApPli aiIate
INSPECTOR COPY