9300 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
auuoBUILDING PROJECT IDENTIFICATION
APPLICA'TIG#J�$ PERMIT -
PoppyBUILDING-ELECTRICAL-PLUMBING-MECHANICAL 9300
INNER PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
PHONE
CONT NAMERA aRs OUTLETS-SWITCHES-RECEP 10,00/1.00
LIc.ND. - /O LIGHTING FIXTURES 10.00/1.00 }
CONTRACTOR S
ADDRESS Sg4.40E'L•y Ueil{� PPLIANCES-RESIDENTIAL 4.00
APHONE 'O PANELS 10.00 DATE OF APPLICATION
ORRCHI ECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEEP.C.NO.
ENGINEER
LIc,No. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
-zip EMP.METER OR POLE INS. 20.00 pA��
ADDRESSTa MOTORS SEE FEE SCH. 9
SERVICE CHANGE 20.00
w o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 �s��ysl ((11�
Fi W I hereby affirm that I am licensed under provisions of Chapter 9 C,b6UANCE DATE
¢ (commencing with Section 7000)of Division 3 of the Business and BLDG. E T. PLG, MECH.
F O i Professions Code, d my license is in full loge-:yld,e ecl ❑ ❑ ❑
Oi 2 O License Class IYTsi -
m F w Dalc_ Contractor L'J!(3,
¢ w OWNER-BUILDER DECLARATION 13LDING PERMIT
E: o A u INFORMATION
w 3 u I hereby al firm that I am ezempl from the Contractor's License MISC.- REFER TO ORD
H u O¢ Law for the following reason.(Sec.7031,5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION g/FT.
my Cade:Any city orcounty which requires a permit to construct,alter,
rt2 ¢ o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
n wO u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
$u he is licensed pursuant to the provisions of the Contractor's License
H z¢ Law(Chapter9(commencing with Section 7000)of Division3 arthe
g 4 O Business and Professions Cade)or that he is exempt(herefrom and OTY. PLUMBING PERMIT FEE
¢ I- the basis for the alleged exemption.Any violation of Section 7031,5 STORIES E CONSTR.
by any applicant for a perm it subjects the applicant to a civil penalty ALTER-DRAIN IEA.) 5.00
of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as BACKFLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the struttore is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,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 b0.FT.FLOOR AREA TOTAL ACREAGE
• himself re through his own employees.provided that such improve-
or improvemenotnt
sold or within
one year
o((,however,the building GAS-EA.SVSTEM-11NC.40UTLETS 8.00
or improvement is sold within pr your of lie did
ot the owner-
builder GAS-EA.SYSTEM•OVER 4 (EA.) 2.00
provewill have the burden of proving that he did not M1uiIJ or int- BUILDING USE
prove for purpose of sale.). R IND CON PB Omer
❑ ],as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 SSESSORS PARCEL NO.
and Professions Code:Ilia 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 contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACTNO, PARCELING.
❑ I ens excmptunder Sec. ,B.&P.C.forthis WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5,00
1 hereby affirm Ihat I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
OV
copy thereof(Sec.3600,Lab.C.).
Policy No. Company
❑ Certified copy is hereby furnished. - FIRE SPRINK ENERGY T 24
Z,g� {/ Certi�q copy is E d with Frye city Inspection division,
Ap(licunt ('_----d- 1,.N MISC.- REFER TO ORD. Y [] NE] y ❑ NE]
CIiRTI FICA'I'fi 017 F.XI.MPT'ION F )M WORKERS' PERMIT ISSUANCE 10,00 FLOOD ZONE A.L.U.C:
d O COMPENSATION INSURANCE PLG.CONTR, LIC.NO. 1OT.AL Y N Y N[3a. Z (This section need not be completed if the permit is for one
hundred dollars(S 100)or less,)
L) O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
U. H mit is issued,I shall not employ any person in any manner so as to
O W hecome subject to the Workers'Compensation Laws of California.
tt Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE'FO APPLICANT: If,after making this Certificate of Ex-
? emption,you should became subject to the Workers'Compensation 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 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.EM.) 6.00 SEISMIC FEE
1 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 ITO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
. information correct y I agree to comply with all city and countPLUMBING
ordinances and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 state laws relating to building construction, my
hereby authorize representatives ins inspection
this city to enter upon the BOILER-COMP Over 100,000 STU)SEE FEE SCH. MECHANICAL
above-mentioned property tarvespof this
purpose:.
(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
may in any way accrue u Inst said City in consequence of the
gr i of this pemli4 MECH.CONT. LIC.NO. MECH.
7-�G- TOTAL TOTAL
hilhature of Applies nl Con tract Dale
OFFICE COPY