8399 APPLICANT TO FILL IN INFORMATION WITHIN RED ONES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMITNUMBER
But LDING . APPLICATION & PERMIT
L ADDRESS -
dl- BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
L, 409 -�0944 8399
OWNPLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
ONE
NAMERAOT s UTLETS-SWITCHES-RECEP 10.00/7.00
H. ✓ m.No. LIGHTING FIXTURES 70.00/1.00
ADDRESS
o APPLIANCES-RESIDENTIAL 4.00
PHONE 1PANELS 10.00 DATE OF APPLICATION
4.OR PANELS (OVER 200 AMPI 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. ' SIGNS TRANS. 3.00 1 {
AARCH OR DDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS. 20.00
ASMOTORS SEE FEE SCH.
ADDRESS
ADDR
SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
¢ o U I hereby affirm that I um licensed under provisions of Chapter 9 ISSUANCE DATE
w G % (commencing with Section MECH-
7000)of Division 3 of the Business and BLDG. ELECT- PLG.
H o z Professions Code,a my license is in full force an effect yt
z License Class Lie.Number hEl El
r o Date I Contractor _
a Y /O / / / BUILDING PERMIT
se ,c ¢ W UILDER DI: �iyTt' -
o a o MISC.- REFER TO ORD INFORMATION
w S u, 1 hereby affirm that 1 am exempt from the Contractor's License VALUATION
F LLoa Law fonhe followingrcason.(Sec.7031.5.Businossand Professions PERMIT ISSUANCE 10.00
Code:Any City or county which requires a Permit to construct,alter.
¢ ¢2O improve,demolish,or repair uny structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEG
Oticrequires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
a w m he is licensed pursuant to the provisions of the Contr ctoi s License
Hzi Law(Chapter 9(umir ing with Section 7000)of Division 3 oflhe �'�J
-¢ Business and Professions Code)or that lie is exempt therefrom and OTY. PLUMBING PERMIT FEE T
¢ ro the basis for the alleged exemption,Any violation of Section 703 t,5 STORIE TYPE CONSTR.
air' by any applicant for a Femur subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(8500).1'.
❑ 1,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 ProfessionsDRAINS-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 docs such work FIXTURES-PER TRAP 5.00 SD.FT FLOOR9REA TOTALACREAGE-
Rentslare not hrough
or offered
pe,If,h ever,such improve- GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
mems are nor intended or offend for sales If,ed Chats the building
or improvement Is sold'within one year of completion, tire owner- GAS EASYSTEM-OVER 4 IEA ) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or ire - . .
- RES IND CON PB Omer .
prove for purpose of sale J. - INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
` licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL N0.
and Professions Code:The Contractor's License Law docs not apply
to an owner Of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
u 'Rcts for such projcO,with a contractor(,)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.2001100.00 TRACT NO. PARCEL NO.
❑ 1 exempt under Set.-,B&P.C,for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACO.FILE NO.
WORK ERS'COMPF;NSATION DECLARATION WATER TREATING EQUIP.,t 5.00
I hereby affirm Ihui'1 have a urtiticatc of consent to self-insure. ZONING
or a eerlifiwte Of Workers'Compensation Insumnee, ,,a certified ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No. Company e.n, ..v
O ❑ Certified copy is hereby(um6hed FIRE SPRINK ENERGY 24
HO Certified cop is filed witll the 'ty ins act/ion division. MISC.- REFER TO ORD. y❑ N❑ y ❑ N❑
cc O1� CERTIFIC E i' i ,IP ,7.v 14Nf /PERMIT ISSUANCE 10.00 FLooD zoNE aL.0 c.
W COMM N TO INSURANCE, SCG.CONTR. LIC.NO. PLG. y❑ N❑ Y❑ N❑
�
This section rmed I be completed if dic permit I ne TOTAL
hundred dollars fSlO orIt..)
U O 1 certify that in tie performance of the work for which this per- DTV. MECHANICAL PERMIT FEE - FEE SUMMARY
LL F mil is issued„I Shull not employ any person in any mann,,so as 10
O become subject to the Workers'Compensation Laws of California.
O w BUILDING
d Date Applicant ALTER OR ADD TO MECH. 5.00 S
} m NOTICE TO APPLICANT: If.after making this Certificate of Ex-
F 2 eruption,you should become subject to the WorkersCompensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must Iorlhwllh comply with
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IO,OODGEM.) 6.00 SEISMIC FEE a 0
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the perfornanre of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.CJ, HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lende'r's Name H EATING UNIT(OVER B.T.U.)9.50
Lender's Address ELECTRIC -
I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00
infornalion is correct, 1 agree to comply with all city and county PLUMBING
..Munn,,, and saW laws relating to building construction, and BOILER-COMP 13 H.P.or 100,000 B.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 for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgntsets, costs and expenses which CONST.TAX
may in any way accrue against Said City in consequence of the PERMIT ISSUANCE 10.00
granting of is permit MECH.CONT. LIG NO. MECH.
TOTAL TOTAL d 7 3e
Sint pp'cat - t c ate
` INSPECTOR COPY
II