C8476 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT lDENTIFICATION PERMIT NUMBER
APPLICATION & PERMIT
amlowc
ADDRESS
- � L/uDy 44N9 BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S
,x� AN CHECK vALIDAT ON
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® GFIAfLLES N. �LJBk6� QTY. ELECTRIC PERMIT FEE 3
I HONE
NAMEncroas OUTLETS-SWITCHES-RECEP 10.00/1.00
uc.No. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00
ADDRESS
r AA PHONE PANELS 10.00 DATE OF APPLICATION
OARCHITECT
R tZs4 • PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
\ E
INVJ T�(�N� SIGNS TRANS. 3.00
ARCOOR ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ESS
ZIP TEMP. METER OR POLE INS. 20.00 _
AEMOTORS SEE FEE SCH.
ADDRDDRESSSS
r. SERVICE CHANGE 20.00
° ¢ K �p1
Hoo LICENSED CONTRACTORS UECLA RATION TEMP.POLE 30.00 q
a u v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
H rt y (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H n z Professions Code,and my license is in full force and effect ❑ ❑ ❑ E]z O ru$' - License Class Lic.Number
o w H w Date Contr in,
Ha Y s BUILDING PERMIT
¢ ¢O re< OWNER-BUILDER DECLARATIOR INFORMATION
E:
3 u 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
a VALUATION
H u o j Law for the following unison.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 10.00
Code:Any city or county which reyuires a permit to construct,alter,
g w Q 0 improve,demoll h,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO.
¢ ¢ O lo� ELEC.
a wO LL reyuires the appbeant for such permit to file a signed statement that TOTAL PERMIT TO
m m he is licensed pursuant to the provisions of the Contractor's License
H, s- Law(Chapter 9(commencing with Section 7000)of Division 3 of the �•L�
E 4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE 7Ae S
Be H p the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
in by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
o1'not more than five hundred dollars($500).):
❑ I,as owner of the 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
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 so.FT.FLOOR AREA .TOTAL ACREACE
himself or through his own employees,provided that such improve- ..
IT are not intended or offered for sale.IG however.the 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 h - . - . .
e did not build or ire- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
O I,as owner of the property,um 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 Code: rhe 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 contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ l am exempt under Sea ,B.&P.C.torthis WATER HEATER W/VENT 6.00
reason
Owner I platet../ WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DE CLARATIO,NV� IUP WATER TREATING EQUIP. 5.00
1 hereby affirm (flat I have a certificate of consent to sell-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab-CJ.
Policy No. Company
O ❑ Certified copy is hereby furnished.
FIRE SPRINK ENERGY T24
Z Z ❑ Certified Copy is fled with the city inspection division. MISC.- REFER TO ORD.
O Applicant y❑ ry❑ y ❑ NE]
CC CERTIFICATE EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00
FLOOD ZONE A.L.UL.
W >
CO,MPFN$ATION INSURANCE
PLG.CONTR, LIC.NO, PLG.TOTAL YE:] ❑N Y ❑ N
EL ❑
O This section need not be completed if the permit is for one
::) Z hundred dollars IS 100)or less.)
L) O 1 Pertly that in the ,c,f.rmmnce of the work fur which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mil is issued,I shall not employ any person in any manner so as to
O L) become subject to the Workers'Compensation Laws of California.
Date A licant BUILDING /
} y NOTICE TO APPLICANT: If,after making this Certificate of fix- ALTER OR ADD TO MECH. 5.00
H ? emption,you should become subject to the Worked Compcnsut ion APPLIANCE 5.00 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 10OXIC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE 3-p
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. MICROFILM
3(1)7,Co,.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I cannily that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
infannation is correct I agree to comply with all city and county PLUMBING
ardin;ome, and state laws rclutlng to building construclion, umI 130ILER-COMP(3H.P.or100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP Over 100,000 BTU)BEE FEE BCH. 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 10.001CONST.TAX
may in any way accrue against said City in consequence of the
grunting of this permit. J MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
re 'ontmctor e
INSPECTOR COPY