8308APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUTI LD1 NG PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING -MECHANICAL
PERMIT NUMBER
8 8
BUILDING
AooREss
n
..S
PLAN CHECK VALIDATION
NAE
CITY. ELECTRIC PERMIT FEE
PHONE
,1
CONNNACTORS NAME
OUTLETS -SWITCHES -RECEP 10.00/1.00
C Ltc No
LIGHTING FIXTURES 10.00/1.00
R To"'
noDREss
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
DATE OF APPLICATION
ARCHITECT
OR
ENGINEER
LIC. No.
PANELS (OVER 200 AMPI 20.00
PLAN CHECK FEE P.C. N0.
SIGNS TRANS. 3.00
ARC Ess ENG.
ADDRIIP
SPECIAL CIRCUIT 5,00
PERMIT VALIDATION
rrEMP. METER OR POLE INS. 20.00
S
APPLICANTS
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
TEMP. POLE 30.00
I hereby affirm that 1 am licensed under provisions of Chapter 9
ISSUANCE DATE
(commencing with Section 7000) of Division 3 of the Business and
I'ro fessions Code, :u d my license is in full force and effect.
LLicenseLlClass_ Lin, Numhe
BL qG.
ELECT.
❑
PLG. MECH.
❑
Date Contractor3=-�^�$.�
BUILDING PERMIT
INFORMATION
OWNIi R:N UILDIiR DIiCLARATIDN
I hereby affirm that I um exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5. Business and NoNsslons
Code: Any City or county which requires a permit to construct, alter,
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 pursuant to the provisions of the Contractor's License
MISC. - REFER TO ORD
VALUATION
�JS
�UU
$/FT.
PERMIT ISSUANCE 10.0
ELEC CONTR. LIG NO.
ELEC.
TOTAL
PERMIT TO
CITY. PLUMBING PERMIT FEE
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
WORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant loacivil penalty
of not more than five hundred dollan, S500)J:
ALTER -DRAIN St VENT -WATER IEA.) 5.00
O I, us owner of the property, or my employees with wage, as
sole compensation, will do the work, and the structure is not
BACK F LOW PROTECT. DEVICE 4.00
OCC. GROUP
RES, UNITS
DRAINS -FLOOR, ROOF, AR EA, COND. 5.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's 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-
menus are not intended or offered for sale. If, however, the building
FIXTURES - PER TRAP 5.00
$0. FT. FLOOR AREA
TOTAL ACREAGE
GAS-EA.SVSTEM-1 6.00
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or ire-
prove for purpose of mIc.l.
❑ 1, as owner of the property', am exclusively contracting with
. . .
GAS - EASYSTEM -OVER 4 (EA) 200
BUILDING USE
R IND CON PB Omer
❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 IEA.) 1.00
licensed contractors to construct the project (Sec. 7044, Business
aI d Professions Cotte: The Con true(or's License Law docs not apply
to in, owner of property who builds or improves thereon, and who
11 ASSESSORS PARCEL NO.
contracts for such projens with a contractor(s) licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
O tum exempt under Sec. ,B.&I'.C. li>r this
reason
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
WORK ERS'COMPFNSAT1ON DECLARATION
1 hereby affirm that 1 have a certificate of consent to self -insure.
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof (Sec. 3800, Lab.C.).
Policy No. Company iT ter- A
'
FIRE SPRINK
Y❑ N❑
ENERGY T 24
v❑ N❑
❑ Certified' py is hereby lu is tc (f(� ��''((''''��
❑_CcRifiea �r ,y is reed wiu, m t��lf$p��mi blVlSl011.
ppplfi..., 1 1 A
MISC- REFER TO ORD.
I ATEOFE. iWvTI PROM RKI°RS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.U.C.
PLG. CONTR. LIC. NO.
TOPLG.TAL
"�ERTI
CO.MPBNSAIION INSURANCE
(This section need not be completed if the permit is lot one
Y ❑ N ❑
Y ❑ N ❑
hundred dollars IS 100) or less.)
1 certify that in the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner so as to
CITY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
!
J� S
become subject to the Workeri Compensation Laws of Catilor m.
Dato Applicant
NOTICE: 'TO APPLICANT: If, after making this Certificate of lix-
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00
PLAN CHECK
emption, you should become subject to the Workers' C'omnensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this Permit shall he deemed revoked.
FEE
AIR HANDLING UNIT (TO 10=C.F.M.) 4.00
AIR HANDLING UNIT (OVER 10=C.EM.) 6.00
SEISMIC FEE
CONS'T'RUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
the 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
Lender's Name
Lender's Address
HEATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
I certify that I have read this application and state that the above
VENTILATION FAN (SINGLE) 4.00
IRfonnution is correct. I agree to comply with all city and aunty
modaurces and state laws relating to building construction, and
PLUMBING
BOILER-COMP13 H.P. of 100,000 B.T.U.) 6.00
BOILER -COMP IOver 100,000 BTUI SEE FEE SCH.
MECHANICAL
hereby ant o ve representatives of this city to enter upon the
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD.
(We) agree to save, indenmify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
ma. any y accrue against said City in consequence of the
gr lin ofthwp,, I.
CONST. TAX
PERMIT ISSUANCE 10.00
MECH. CONT. LIC. NO.
MECH.
•
_
TOTAL
TOTAL
T /
Sigi re of Applicant/ on ractor ate
INSPECTOR COPY