8456 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
annRE55
O , 4VD BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 8456
O NER'S J c T- /" PLAN CHECK VALIDATION
NAME QTY.
RacionELECTRIC PERMIT FEE
ONE
NAAMEs OUTLETS-SWITCHES-RECEP 10.00/1.00
M# LIC.NO, LIGHTING FIXTURES 10.00/1.00
.o RACroR'$
ADDRESS PPLIANCES-RESIDENTIAL 4.00
T PANELS 10.00 DATE OF APPLICATION
A C ITEM
DR PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
uc.NO SIGNS TRANS. 3.00
ADDRESS ENG.
SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
&414- ZIP EMP.METER OR POLE INS. 20,00 1r-
ADDRESS
AMOTORS SEE FEE SCH.
ORE55 r
SERVICE CHANGE 20.00 J
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
¢u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATED)
y ¢ N (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F w z Professions Code,and my license is in full force and effect. ❑ ❑ ❑
zO m - License Class Lic.Nunlhur
m - o Date - Contractor
a m f
BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DECLARATION
¢ w u INFORMATION
w ;LL m I hereby affirm that 1 am exempt from the Contractor's License MISC. REFER TO ORD VALUATION S/FT.
F .. O a Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 1o.00: ale,
Code:Any city orcounty which requires a permit to construct,alter,
aa s- 2O improve,demolish,orrepair any structure,prior to its issuance,also ELEC.CONTR LIC.NO. ELEC.
¢ requires the applicant forsuch permit to file a signed statement that TOTAL �.. PERMIT TO
E
m n he is licensed pursuant to the provisions of the Contractor's License
r z a Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe J
Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
rc l O 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 penally ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars(S500).):
❑ I,as owner of lire property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
S himself or through his own employees,provided that such'in
prove-
mems are not intended or offered for sale.If,however,lire building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM-OVER 4 IEA) 200
builder will have the burden of proving that he did not build or far- - . . .
- BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 3000 RES IND CON PS Otter
❑ I,as owner of Ilse properly,am exclusively'contracting with . ❑ ❑ ❑ ❑ ❑
licensed Contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO:
and Professions Coda:l'he Contractor's License Low does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts to such projects with a contruclortsl licensed pursumv to SEWER-SAN V-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ tom exempt under Sec. ,B.&RC.far this WATER HEATER W/VENT 6.00
reason
Owner lr ito / Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE N0.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby mfinnIlan 1 little a certificate nl Consent it, df insu rc, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
Copy thereof(Sec.3800,Lab.CJ.
Policy No. Company
O ❑ Certified copy is hereby famished. FIRE SPRINK ENERGY T24
z Z. ❑ Certified copy is filed with the city inspection division.
O Applicant MISC.- REFER TO ORD. Y ❑ N❑ I Y ❑ N❑
~ vt PERMIT ISSUANCE 10.00
� - CIi R'1'1 PICATIi 1'EXEMPTION[ NS pR N WORKERS' FLOOD ZONE A.L.U.C.
W > COMPIiNSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
Z (This section need not be completed if the permit is for one TOTAL Y[D NE] Y E] ❑
N
hundred dollars(S I O0)or Is,.)
U _O 1 cerlily that in the perfonuanc'e of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
W F mil is issued,I shall not employ any person in any manner so as to
Ow become subject to the Workers Compensation Laws of Cahlornio. BUILDING
Q_ Date-Applicant ALTER OR ADD TO MECH. 5.00
} N NOTICE TO APPLICANT: If;aftar making this Cenifmalc of Ex-
F-. 2 emption,you should become subject to Ole Workers'Compensation APPLIANCE - 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
V such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10)000C.F.M.) 4.00
CONSTRUCT ION LENDING AGENCY' AIR HANDLING UNIT(OVER 10,000CEM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of lire work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 r�
Lenders Address ELECTRIC
I certify flat I have read this application and state that the ahove VENTILATION FAN (SINGLE) 4.00 r
. intornlation is correct. I agree to comply with all city and county PLUMBING
ordinances and stale laws relating tot building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city No-cmer upon the BOILER-COMP love,ioo,00o BTUISEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(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 City in consequence of the
granting of this permit MECH.CONT. LIC.NO. MECH.
TOTA` TOTAL
t I pli oro ac or ale
INSPECTOR COPY