10704 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT IDENTIFICATION - PERMIT NUMBER
BUILDING APPLICATION & PERMITA Coy?, 10704 6 f`� j BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 1 O Z O 4
\ OWNER'S / 9W-111y'" PLAN CHECK VALIDATION
\T/• NAME
//) q QTY. ELECTRIC PERMIT FEE
O I,/ rV PHONE -
CNAME
ONTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.No ILIGHTING FIXTURES 10.00/1.00
CONTRACTORS
ADDRESS APPLIANCES-RESIDENTIAL 4.00
CONTR
PHONE - PANELS ' 10.00 DATE OF APPLICATION
OR
RCHITecT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
AARCH.OR DDRESS ENG. 1 SPECIAL CIRCUIT 5,00 - PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS. 20.00
ADDRESS • MOTORS SEE FEE SCH.
SERVICE CHANGE - 20.00
Cw o o LICENSED CONTRACTORS DECLARATION
v I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and
y¢ n BLDG. ELECT. PLG. MECH.
F 7 i Professions Code,and my license is in.full force and effect. ❑ ❑ ❑
oi W License Class Lic.Number
r w J Date Contractor
¢ ae ¢ a OWNER-BUILDER DECLARATION BUILDING PERMIT
c d U - - INFORMATION
X ;u r I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD'
a VALUATION $/FT.
HLL0< Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 '
w wCode:Any city or county which requires a permit to construct,alter,
Ix t< ¢O improve,demolish,or repair any structure,prior t0 its issuance,also ELEC.CONTR. LIC.NO. ELEC.
iu requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w v, he is licensed pursuant to the provisions of the Contractor's License / /`
Fi) Law(Chapter 9(commencing with Section 7000)of Division 3 afthe �,e...B �i ��Yd
¢ Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
¢ H ro the basis for the alleged exemption.Any violation of Section 7031.5 STORIES T PE CONSTR.
i by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN BE IEA.) 5.00
of not more than five hundred dollars(5500).): '
❑ 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
• property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SYSTEM-1INC.4 OUTLETS 6.00
ments are not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PS Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 ,� � -
❑ 1,as owner of the property,am.exclusively contracting withQ El [I
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 contractorts)licensed pursuant to SEWER-SANITARY-STOR ft/10.00
the Contractor's License Law. TRACT NO, PARCEL NO.
pt undegS
❑ Ia xem -.� ,B.&P.C.for th
reason is- WATER HEATER W/VEN 6.00 - -
Ow Date WATER SYSTEM rn100
ACC.DATE ACC.FILE NO,
WORKERS'COMPENS ON DECLARATION WATER TREATING 5.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified 104 oti nn
copy thereof(Sec.3800,Lab.C.). r
Policy No. Company / -
0 ❑ Certified copy is hereby furnished. a FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- I EFER TO ORD.
O Applicant - Y C] N Y ❑ No
CC PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
Lu CERTIFICATE E EXEMPTION FROM WORKERS'. I
W � COMPENSATION INSURANCE PLG.CONTR. - LIC.NO. PLO.
Z (This section need not be completed If the permit is for one _ TOTAL - Y E] N� Y [:] N�
hundred dollars IS 100)or less.)
U O I certify that in the performance of the 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
0 W become subject to the Workers'Compensation Laws of California.
y Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} ED NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F 2 emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000OF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,0WC.RM.) 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 HEATING UN IT 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
.� 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 state laws relating to building construction, and BOILER-COMP113 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,judgments,.costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
to 'n any way accrue inst said City in consequence of the
nl
Bgdhis it MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
nature of pplicant/Contract Date
OFFICE COPY