8526 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDING PROJECT I DENTI FI CATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 8526
ADDRESS
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNERS' PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
vxe .ONE X7-4 Cl 7
NAMERAcro s OUTLETS-SWITCHES-RECEP 10.00/1.00
Lie.NO. LI GHTING F IXTU RES 10.00/1.00
DNRRAcrDR's
ADDRESS PPLIANCES-RESIDENTIAL 4.00
A
PHONE PANELS 10,00 DATE OF APPLICATION
AARRCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
O
ENGINEER
Lm.No. SIGNS TRANS. 3.00
ARCH.OR ENG, SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
RESS
ZIP TEMP. METER OR POLE INS. 20.00
APPLICANT'S
ADDR
APPLICANTS
ESS MOTORS SEE FEE SCM. C-
J
SERVICE CHANGE 20.00
woo LICENSED CONT RACfORS DECLARATION TEMP.POLE 30.00
a z w 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
<u (commencing with Section 7000)of Division 3 of the Busines and BLDG. ELECT. PLG. MECH.
F H z Professions Code,and my license is in full force and effect. ❑ ❑ ❑
z0,n License Class Lie.Number
4 m w Date,.Contractor
sE
aM ai OWNER-BUILDER DECLARATION BUILDING PERMIT
¢ v INFORMATION
o n
I hereby alfinn that 1 am ex out from the Contractor's License MISC.- REFER TO ORD
LL 0 J Law for the following reason.(Sec.7031.5,Business and 1'rofcssions VALUATION $/FT.
_ PERMIT ISSUANCE 10.00
Code Any city or county which requires a permit to construct,alter, t
Q improve,demolish,or repair any structure,prior to its PSuanCe,also ELEC.CONTR.' LIC.NO. r ELEC.
E
m S, requires the applicant for such permit to file a signed Stademmnt that TOTAL PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License
F z i Law(Chapter 9(commencing with Section 7000)Of UivisionJ of the Ccs GN�
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE �J e
E x 0 the basis for the alleged exemption.An
e- T g p the
of Section 703 L5 STORIES TYPE C STR.
a ; m by any applicant for a purtnit subjects the applicant ton civil penalty
of not more than five hundred dollars(55001.): ALTER-DRAIN -WATER IEA.) 5.00
❑ I,as owner of the property,or my employees will, wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
sole compensation,will do the work,and the Structure,s not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contrnctoi 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 SD.FTFFLOOD AREA TOTAL ACREAGE
Inimsellor through his own employees,Provided that such improve-
ments are not intended or offered for sale.If,how eve r,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 (EA) 2.00
builder will have the burden of proving that he did not build or ire- GAS . - .
- BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON 'PB Omer
I,as,owner of the property',am exclusively contracting with ElEl El El 1:1li sed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL 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:I comractods)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. Z_!2-- TRACT NO. PARCEL NO.
❑ lam exempt,order Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
on
Owner Dale WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
\VORKIiRS'COM NIiNSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate efconsent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.CJ.
Policy No. -- Company
❑ Certified J`r copy is hereby furnished. 71f 7 FIRE SPRINK ENERGY T 2
Z Z ❑ Certified copy is fled with the city inspection division. MISC.- REFER TO ORD.
17 Applicant Y ❑ N❑ y ❑ N❑
w CERTIFICATE OF EXEMPT FROM WORKERS' PERMIT ISSUANCE _.10.00 C�- FLOOD ZONE A.L.u.c.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O (This section need noNbe completed if tine permit is for one TOTAL -3Y❑ NE] Y❑ N❑
2 hundred dollars 1$100)'or less.) r
U O I certify that in the perfornnance of the work for which this per. OTY MECHANICAL PERMIT FEE FEE SUMMARY
L.L I- n.it is issued, 5ha11 not employ any person in any manner so as to
O U become subject to the Workers'Compensation Laws of California.
y Date, Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE TO APPLICANT: If,alter making this Certificate of Ex-
F Z e,nption,you should become subject to the Workers'Compensation 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 10=171F.M.) 4.00
CONS')'RUC'I'ION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000C.EM.) 6.00 SEISMIC FEE
I hereby dffinn that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work fir which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address H EATI NG UN IT IOVER 100,000 B.T.U.)9.50 ELECTRIC,
i
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 r
in fi na ccs n estate. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction. and ' BOILER-COMP(3 H.P.OP 100,000 B.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 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
Inay i, y way-accrue against said City in consequence of tile,
gun ' nl'tlhis•ferm MECH.CONT. LIC.NO. ECH.
55..yy5 _ / TOTAL TOTAL
,g fiM
tITR'ol APPI¢anl/C , L -
r
INSPECTOR COPY