9281 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USIi BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON - PERMITNUMBER
BUILDING APPLICATION & PERMIT ^ ^
AO° y G
- BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
81
OWNER'a PLAN CHECK VALIDATION
NAME f� �`s QTY. ELECTRIC PERMIT FEE
ON PHONE .
HnrNn¢AOTORS 17
( OUTLETS-SWITCHES-RECEP 10.00/1.00
'� Llc.rvo.
ADDRESS LIGHTING FIXTURES 10.00/1.00
ADciGR•s PPLIANCES-RESIDENTIAL 4.00
42!2AOORE5 '/
36 66�ZONE 3 7�y PANELS 10.00 DATE OF APPLICATION
OORARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.L.NO.
ENGINEER
LIC.No. SIGNSTRANS. 3.00
ADDDRESS ENO' SPECIALCIRCUIT 5.00 PERMIT VALIDATION
'ZIP EMP.METER O POLE INS. 20.00
APP IRCESS MOTORS •.w SEE FEE SCH.
AOOREss
J SERVICE CHANGE 20.00
w o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 lA��
a CI w 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
w < e. (commencing with Section 7000)of Uivisian 3 of lite Business and �, r� C BLDG. ELECT. PLG. MECH.
Z OD Professions s n license is in full forffe� (f1sct. ❑ ,.y., ❑ ❑
m License Class�� -y Lic.NumberY Yp['`c'I
,L,t H w Date J�T? V Contractor
a se s , BUILDING PERMIT
Ic M ¢ OWNER-BUILDER DECLARATION
o s U INFORMATION
K
; w I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION SIFT.
H LL 0 J Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 Q
Iw0 � Cade:Any city or county whichrequiresa permit to construct,alter,
ce 5 Q O improve,demolish,or repair any structure,prior to its issuance,also E ON ��• LIC.NO. ELEC. O
O LL requires the applicant for such permit to file a signed statement that S/;�/f�� TOTAL PERMIT TO
K
S he is licensed pursuant to the provisions of the Contractor's License �L
r z i
Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
M t the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
d ; by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN VENT-WATER (EA.) 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 TOTAL ACREAGE
• himself or through his own employees,provided that such improve.
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 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 im- - . BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 3000 RES IND CON PB Other
❑ 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 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 to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT N0. PARCEL NO.
❑on I am exempt under Sec,-,B.&P.C.for this WATER HEATER W/VENT - 6.00
reas
Owner Dale WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORK ERS'COMP,E N.SATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I'have a certificate ofconsenl to self-insure, ZONING ENG.SITE NO.
or a.certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.CL
Policy No. Compapy ,
O 0 Certified copy is herebgx furnished. FIRE SPRINK ENERGY T-24
'211Certifle�}� ty Inspection division. MISC.- REFER TO ORD.
Z Q APIT111111111 t 20 Y ❑ N[] Y ❑ NEI
CCL2PERMIT ISSUANCE 10.00 -
LU CERTIPICATE.OF EXEMPTION FROM WORKERSFLOOD ZONE A.L.U.C.'
d ? COMPENSATION INSURANCE PLG.f pNTs LIC.NO. _ PLO
:D Z (This section need not be completed if the permit is for BeoTOTAL Y❑ N Y E] IN
❑ ❑
hu1 cert dollars(5100)pe less.) ,.-
U. O I certify that h the performance of the work for which this per QTY. MECHANICAL PERMIT FEE FEE SUMMARY
U.0 H- mit is issued.I shall not employ any person in any manner so is to
'become subject to the Workers Compensation Laws of California.'" ` + ' -
a - Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Cade, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT ITO 10AMC.F.It 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10M C.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. HEATING UNIT(T0 100,000 B.T.U.) 6.00 MICROFILM
3097,Civ.CJ.
Lender's Name HEATING UNIT(OVER 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-COMPI3H.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 properly for inspection purposes.
(We) agree to save, indemnify and k > harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgmel sls and expenses which CONST.TAX
may in any way a agai fly in consequence of the PERMIT ISSUANCE 10.00
grantingofl i It. MECH.CONT, LIC.NO. MECH.
TOTAL TOTAL
Signature of Applicant/Contractor Date
OFFICE COPY