8493 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
'BU I LDING PROJECT I IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
a an2 �� BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 8493
O E 'S fff...���
PLAN CHECK VALIDATION
N QTY. ELECTRIC PERMIT FEE
• ONE
'E
CONTRACTOR
ME UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.N%W LIGHTING FIXTURES 10.00/1.00
no RES
TORS APPLIANCES-RESIDENTIAL 4.00
PANELS 10.00 DATE OF APPLICATION
A ITECTOFT �•//'' PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
uc.NO, SIGNS TRANS. 3.00
ADDRESS ErvG' SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP rrEMP. METER OR POLE INS. 20.00
ASMOTORS SEE FEE SCH.
ADDREDDRESSS
SERVICE CHANGE 20.00 V
w
'09 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
c U H 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
H < w commencing with Section 7000)of Division 3 of the Business and - BLDG. ELECT. PL MECH.
F N z rofessions Cc and J ccluc is in full fm'-a ff / ❑ ❑ ❑
icemse Class Lic.Number
r Out Con, for
-�- yet,
re ac a "r •' o ER-BUILDERXIL RA I Nr BUILDING ION
F. o a ° INFOR TION
X ;LL y I hereby affirm that I am exempt from Om Contruc r s Licens MISC.- REFER TO ORD
FLLH � Law for the following reason.(Sec.703 ES,Business and Professions PERMIT ISSUANCE 10.0
VALUATION
Code:Any city or counly which requires a permit loco struct.alter,
O
Qec¢ 0 Improve,demolish,Or repair any structure,prior to Its Issuance,also ELEC.CONTR. LIC.NO. ELEC.
¢ requires the applicant for such permit to file a signed statement that TOTAL
e w m" he is licensed pursuant to the provisions of the Contractor's License ERMIT TO
r z¢
Law(Chapter 9(commencingwift Section 7000)of Division 3 oflhe
i o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ I-m the basis for the alleged exemption.Any violation of Section 7031.5 5T E5 T PE CONSTR,
a by any applicant for a permit subjects the applicant to a civil penalty gLTER-DRAIN&VENT-
WATER
of not more than five hundred dollars 18500).1:
❑ L as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
tended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law docs not apply to an owner of
property who builds or Improves thereon,and Who does such work FIXTURE6-PER TRAP 5.00 5 T,FLOOfl AflEA
mends are not intended or offered for sale.If,however,the builOTAL ACREAGE
• himself or through his own employees.provided that such improve-
ding GAS-EA.SYSTEM-1 INC.INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or im- - BUILDING USE
prove for purpou ofsalp.l. INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
❑ I,as owner of the property,am exclusively contracting with
licensed contractors ED construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B.' 6.00 ASSESSORS PARCEL NO.
11 0
and Professions Code:The Contractors License Law does not apply
m an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractor(.)licensed pursuam m
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
- ACC.DATE ACC FILE NO.
WORKERS'COMPENSA'I ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a sensation of mance,Or scl entified
(ITo a certificate of Workers'Compensation Insurance,Ora certified ZONING ENG.SITE NO.
copy thereof l Sec.3800.Lamgr
Policy N Company
❑ Certified
ified copy is hereby furnished.
Z ❑ Certified copy is filed with the city inspection division.
FIRE SPRINK ENERGY T-24
O Applicant MISC.- REFER TO ORD. Y N� Y ❑ No
� N CERTIFICATE OP EXEMPTION FROM WORKERS' PERMIT ISSUANCE FLOODZONE A.L.u.c.
W COMI'fiNSAT10N INSURANCE PLG.CONTR. EIC.NO. PLG.
d O (This section need not he completed if the permit is for one TOTAL Y� N� Y � ry
D Z hundred dollars IS 100)or less.)
V O 1 certify that in the performance of the work for which this per- QTXr MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued, I shall not employ any pars n in any moons so as to
beco_r71j sybpc]&� A Workeri mpens I aws C fornix.
> y Uat Appliexnt ALTER OR ADD TO MECH. 5.00 BUILDING
} m NOTICE: TO APPLICANT: I Water making th' urti feet, 'x-
F ? coalition,you should become subject to the Wo m'Comps ation 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 1Q000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=r-F.M.) 6.00 SEISMIC FEE
I hereby affirm that (here is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec.
3097,CMCJ. - HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.19.50 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-COMP 13 H.P.or 100,000 B.T.U.) 6.00
r hereby authorize representatives of this city to enter upon the BOILER-
above-mentioned property for inspection purposes. - COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
Cu(We) gree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
In 'n any way ace le against s ' City 'n consequence of the PERMIT ISSUANCE 10.00
gr t[i gOf is --------
per CONT. LIC.NO. MECH.
roTAL TOTAL
signature of Appli�an/ nlractor Date
OFFICE COPY