C8705 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NGYROJECT I DENTI FICATI ON PERMINUMBER
BUILDING APPLICATION & PERMIT.
ADDRESS 'W
8705e BUILDING- ELECTRICAL-PLUMBING-MECHANICAL v
OWNER'S
NAME PLAN CHECK VALIDATION
�/ /� �y/r) QTY- ELECTRIC PERMIT FEE
P � /� A PHONE
CONTRACTOR'S
��•.. NAME OUTLETS-SWITCHES-RECEP 10.00/1.00 '
LC.No, LIGHTING FIXTURES 10.00/1.00
ADDRESS Tons PPLIANCES-RESIDENTIAL 4.00
,404) A60k Q PHONE7:2-ICD PANELS 10.00 DATE OF APPLICATION
ARCHITECT -20.
RCHITECTPLAN CHECK FEE P.C.NO.
ENGINEER
OR PANELS (OVER 200 AMP) 20.00
LIC.NO. SIGNS TRANS. 3.00
ADDRESS ENc. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ANTS ZIP EMP. METER OR POLE INS. 20.00
APPLIDDRESS
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
w o o LICENSED CONTRACTORS DECLA♦ryp TION TEMP.POLE 30.00
a u 1 hereby i ffinm that I am licensed under .to
si.,is of Chapter 9
2 w ( ISSUANCE DATE
(commions Code,
Section 700e)i in Division fuse Business and BLDG ELECT. PLG. MECH.
0 w i Professions Code,and 2 license is in full force and effect ❑ ❑ ❑
z O m - License Class _1-.e,.Number G��
O a H Dole
C_` Conlmclo[
BUILDING PERMIT
¢ ¢ w a OWNER-BUILDER DIiCLARA'TION
A o o " INFORMATION
; 0 I hereby uffrm that I um exempt from the Contrudor's License MISC.- REFER TO ORD
Lo Law for the following reason. 7031.5.Businessand Professions PERMIT ISSUANCE VALUATION g/FT.
Code:Any city orcounty which requires a permit to construct,alte,, 10'00 J)
QBE at 0 Improve,demolish,or repair any structure,prior to its Issuance,also ELEQ CONTR. LIC.NO. ELEQ
iL m LL requires the applicant for such permit to file a signed statement that TOTAL
u w he is licensed pursuant to the provisions of the Contractors License PERMIT TO
Fi
Law(Chapter 9(Commencing with Section 7000)ofDivision 3 ofthe
Q
4 D Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r the basis for the alleged exemption.Any violation of Section 7031.5 BTO ES TYPE CONSTR.'
m
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ 1,as owner of the rmpcoy,'or my cnsployecs with wages as BACK FLOW PROTECT. DEVICE 4.00 oce.cROUP RES.UNITS
(heir Sole compensation,will do the work,and the structure,is not
intended or offered HIT 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.Er.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees, le.If.ho that such int building
or nts improvemen notnt is sold or within
ed one or year
If. the theo ding GAS-EA.SYSTEM-1INC.4OUTLETS'6.00
or improvement is sold within one year oft he didl ion,the own
builder will have the burden of proving that he did not build or int- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove 1,aso neeose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND Co Pa Omer
❑ L as owner of the property,he exclusively contracting with ❑ O
licenred contractors od to construct the project(Seo 7044,of apply
LAWN SPRINKLERS-1 INC 5 V.8. 6.00 ASSESSOR P CELNO.
10!Professions Code:The hontuild s s License Law docs not Apply
co an owner of property who haico tr improves Insrcnn,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
ue Cont for such ceseprojects with u contrador(s)license(]pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL No.
❑ lam exempt'under Sec. ,B.&1'.e,.for tits
reason WATER HEATER W/VENT 6.00
0.,her Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate ofconsent to self-insure,
or a certificate of Workers'Compensation Insurance,or a Certified ZONING ENG.SITE NO.
copy thercoffScc,3800,Lab.C.).
Policy No Cnlnpuny
O ❑ Ccr Ilied cop is hereby wind, J.
Z Z �r Certified copy is filed with the city inspection division.
FFIRE SPRINK ENERGY T�sa
O p'ffpTlcant;04 �" XA MISC,- REFER TO ORD. r NE] Y � N[-]= i2. CERTIFICATE OP EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU > COhIPF.NSA'1'ION INSURANCE PLG,CONTR, LIC.NO. PLG.
CL CI (phis section need not be completed if the permit is for one TOTAL V N� Y❑ NF]
Z hundred dollars(S 100)or less.)
U O I certify [hat in me performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mi[ is issued,I shall not employ any person in any nhanner so as to
U L) become subject to the Workers'Compensation Laws of California.
Q. ' Dam Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>_ to NO]IC17 '1'O APPLICANT': If,after making this Certificate of fix-
„ ranptiou,you should beconse subject to file Workers'Compmnsation APPLIANCE 5.00 PLAN CHECK
Provisions of the Labor Code, you must forthwith conhply with
U such provisions or this permit shall be deemed revoked, AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.F.M.) 6.00 SEISMIC FEE
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
3097,Civ,C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name k
Lender's Address H EATI NG UNIT IOVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that 1 have read this applicarion and slate that the ubovc VENTILATION FAN (SINGLE) 4.00
infunnotion is correct.I agree to Peith
omply wall city and county PLUMBING
ordinunccs and star, laws relating to buildi........nstruction, and BOILER-COME(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this' city ,Amir soon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned-property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino a ainst liabilities,Judginqpq costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
May in a way accfue ' ainsl;ICity in consequence of the
grantin this permit' MECH.CONT. LIC.N0. MECH.
1 /y
- o TOTAL TOTAL S�llz
" n u plic n C l c or Dale d
INSPECTOR COPY
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