8557APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING -ELECTRICAL- PLUMBING -MECHANICAL
PERMIT NUMBER
p C
o J07
BUILDING
ADDRESS
U
O E ��j
NAME �VQ-2.7 _969
OTV. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
4;Ac 4.S14-0 4Syoi�NE i -9171/
RAc o's
-DAME
UTLETS-SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
LC. NO.
CONTRACTORS
CONTRA
APPLIANCES - RESIDENTIAL 4.00
PANELS 10.00
PHONE
DATE OF APPLICATION
ARCHITECT
OR
ENGINEER
IJC.NO.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
noxa Ess ENC. _
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00
2IP
0 /641
APs
Aoo ERIESS REss
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
( i
LICE NSIiD 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 Class Lic. Number
ISSUANCE DATE
BLDG.
El
ELECT.
Ll❑
PLG.
MECH.
. )ate Contractor
c
BUILDING PERMIT
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License
Law for the following reason. (Sea 7031,5, Business and Professions
Code Any city or county which requires a Permit to construct, alter,
INFORMATION
MISC.- REFER TO ORD
PERMIT ISSUANCE 10.00
vALunn ON
S/FT.
,
ELEC. CONTR. LIC. NO.
ELEC.
TOTAL
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 puRnart t0 the provisions of the Contractor's License
Law (Chapter 9 (commencing wiOl Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
PERMIT TO
OTV. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit Subjects the applicant to a civil penalty
of not more than five hundred dollars (8500)):
'
ALTER -DRAIN -WATER IEA.) 5.00
❑ 1, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 4.00
OCG GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, CONDE 5.00
role ideal or offered for sale (Sec. 7044, Business and Pmfesslons
Code: The Contractors License Law does not apply to an owner of
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
Iliarcnof intended or offered for sale 11, however, the building
FIXTURES -'PER TRAP 5.00
so. FT FLOOR AREA
TOTALACREAGE
GAS - EA- SYSTEM -11NC. 4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that h e did not build or ice-
prove for puryosc of sale.).
❑ 1, as owner of the property, am exclusively contracting with
- . -..
GAS EASYSTEM OVER 4 IEA) 200
BUILDING USE
RES IND CON PB Other
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct the project (Sec 7044, Business
and Professions Cade. The Contractors License Law does Hot apply
to an owner of property who builds or improves thereon, and who
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
ASSESSORS PARCEL NO.
'
LAWN SPRINKLERS - OVER 5 (EA.)1.00
contracts for such projects with a contmctons) licensed pursuant to
the Contractor s License Law.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
❑ Iran exempt under Sec .BAP.C. for this
reason
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
WORK ERS'C011PfiNSn ON DBCI-ARATION
I hereby affirm that I have a certificate o f consent to self -insure,
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG- SITE NO.
copy thearof(Sec. 3800, Lab.CJ,
'
Policy No. Company
FIRE SPRINK
Y❑ N❑
ENERGY T 24
Y❑ N❑
❑ Certified copy is hereby famished_
❑ Certified copy is filed with the city inspection division.
Applicant
MISC.- REFER TO ORD,
CiiRTIFICA'FEOF Ii XIiMPTION FROM WORKERS'
PERMIT ISSUANCE 10.00
FLOODZONE
A.LU.C.
PLG. CONTR. LIC. NO.
PLG.
TOTAL
• COMPF,NSATION INSURANCE
(This sectionneed not be completed if the permit is for one
Y ❑ N[_Y
E]N❑
hundred dullars($100) or less.) '
I certify that in the performance of the work for which this per-
alit is issued, 1 shall not employ any person in any mammr so as to
OTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to the Workers' Compensation Laws of California.
Date Applicant
ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: If, alter making this Certificate Of Ex-
APPLIANCE 5.00
PLAN CHECK
emption, you should become subject to the Workers'Compensation
provisions of the Labor Code, you most forthwith comply with
such provisions or this permit shall be deemed revoked.
FEE
AIR HANDLING UNIT (TO 10=C.F.M.) 4.00
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
EXHAUST HOOD (WITH DUCT). 5.00
tire performance of the work for which this permit is issued (Sec
3097, Civ.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UNIT 100,000 B.T.U.)9.50
ELECTRIC
'. //
NO /
Lender's Nanta
Lender's Address
Icertify that l have read this application and state that the above
VENTILATION FAN (SINGLE) 4.00
information is correct 1 agree to comply with'city and County
todumnccs and state laws relating to building construction, and
PLUMBING
BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEESCH.
MECHANICAL
hereby authorize mpm,Sdtatives of this city to enter upon the
above-mentioned pmpctly for Inspection purposes.
MISC. - REFER TO ORD.
(We) agree to save,' indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs antl expenses which
may in any way accrue against 'd Cily in consequence of the
CONST. TAX
PERMIT ISSUANCE 10.00
gra 'ng of thisperm' .
H. CONT. LIC. NO. .
MECH.
� ppl ant nl e[ ]ale
TOTAL
<stl`a
TOTAL
[/ r INSPECTOR COPY