C8575 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT 5 5
ADDRESS
1111"8
X BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
OWNER? P4 1 016
7J N CHECK VALIDATION
\ NAME pUl�7/J Z'cl"~f� OTY. ELECTRIC PERMIT FEE
HONE
CON NAIV Rs UTLETS-SWITCHES-RECEP 10.00/1.00
LIC NO. LIGHTING FIXTURES 10.00/1.00
ADDRRACroR's
ADDRESS APPLIANCES-RESIDENTIAL 4.00
CONTRA
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECTPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
uc.NO SIGNS TRANS. 3.00
ADD Ess ENG. SPECIAL CIRCUIT 5.0Q PERMIT VALIDATION
eap TEMP.METER OR POLE INS. 20.00
APPLICANT MOTORS SEE FEE SCH. (-
SERVICE CHANGE 20.00
° ¢ .
r O o LICENSED CONTRACTORS DECLARATION TEMP.POLE30.00
< u w I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
y
z (commencing with Section 7000)of Division 3 of the Business and a HBLDG. ELECT. PLG. MECH.
r z y z Professions Code,and my license is in full force and effect ❑ El 1:1 ❑
Z w o License Class Lie.Number q
m H w Dam Contractor P
a Y 9 BUILDING PERMIT
¢ ¢ a OWNFR-BUILDER DECLARATION -
0 o O INFORMATION
st ; n y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
LLOa Lad for the followingmason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 vALunnON
wf Code:Anycity Drc.Lnt,whichomniresapennit toconstnmt.alter. A.^
> p p Y s to its issuance,also ELEC.CONTR. LIG NO.
¢ ¢ ¢ O improve.demolish,or re air an structure.prior ELEC.
ar
O ¢ requires the applicant for such permit to file a signed Statement that TOTAL PERMIT TO
A w he is is licm¢ed pursuant to the provisions of the Coulnmtor's License
A
Law(Chapter 9(commencing with Section 7000)of Division 3 of tire
io Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE A'MO�rJry S%�t/C%
¢ I- m the basis for the alleged exemption.Any violation of Section 7031.5 p STORIES (TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil Penalty '4
., of Rot more than five hundred dollars(S500).): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ 1,as owner of the properly,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended ar offered for sole (See 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner(it
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO,FT.FLOOR AREA TOTAL ACREAGE
-• himself re through into his own employees.provided that such improvr
himself c r his or empld for ees.provided
that suhe..lroo ng GAS-EA.SYSTEM-1INC-4OUTLETS 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 an. BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 RES IND CON Pe Omer
❑ 1,as owner of the property,am exclusively contra . .
cting 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: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 a contractions)licensed pursuant 1. SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
O I ant cxcmpt under Sec.-,B.&P.C.fur this WATERHEATER W/VENT 6.00 ,_s
reason "s. I
Ownel- .fltlfySra Dmc WATER SYSTEM 5.00 ACODATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I Inne a certificate of consent to xelf-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Iah.C).
Policy No. Conmuny
O ❑ Certified copy is hereby furnished.
FIRE SPRINK ENERGY T-Z4
Z
C) ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O Applicanty❑ ry❑ y ❑ N❑
~ w PERMIT ISSUANCE 10.00
LU - CERTIFICATE OP EXEMPTION NS PROA1 WORKERS' FLOOD ZONE ALU.C.
CL COM ,Of 1),TI ma INSURANCE PLG.CONTR. LIC.NO. PLT.
CL O (This section need not be mameted if the Derinit is for one TOTAL V❑ N❑ Y ❑ N❑
2 hundred dollars($100)or less,)
U O 1 certify that In the performance of lite work for which this per, QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued.I shall not employ any person in any manner so as to
U become subject to the Workers Compensation Laws of California.
U Date Applicant BUILDING
} h NOTICE TO APPLICANT': If,after making this Certificate of fix- ALTER OR ADD TO MECH. 5.00
F Z clap(ion,you should bcconw subject to the Workers'Compcns:nion 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 10MC.F.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE da
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work Rsr which this permit is issued(Sec. MICROFILM
3097,CL C.r HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender i ddy HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's A..U,
AELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• information is correct. I agree to comply with all city and county PLUMBING
ordinances and %rate laws relating to building construction, and BOILER-COMP(3H.P.or100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property 1'orinspedion purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
grantingof lhlspermit. MECH.CONT. LIC.NO. MECH.
/' TOTAL TOTAL SZE
Siginatififf o bean(Contra or to If
INSPECTOR COPY
I