9242 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -,USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDEss
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME CITY. ELECTRIC PERMIT FEE
'id If L PHONE=-86, ,
AME
NACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
CAA, f.Q 11C,NO. LIGHTING FIXTURES 10.00/1.00
RAcrolas PPLIANCES-RESIDENTIAL 4.00
AD PE55
PHONE PANELS 10.00 ;; DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.No. SIGNS TRANS. ,3.00
AARCH OR DDRESS ENG. _ SPECIALCIRCUIT 5.00 PERMIT VALIDATION
'
ZIP EMP.METER OR POLE INS. 20.00
AArvr'a
ADDREDORESS MOTORS SEE FEE SCH. n .
SERVICE CHANGE 20.00
TEMP.POLE 30.00
Doo LICENSED CONTRACTORS DF.CLAHATION /
F Z w 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
(commenclny with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F vD i Professions Code n yy license is in full force a effect.
z o - Licentt Class J(a._-Lic.Number��Z2d- ❑
Date Contractor
BUILDING PERMIT
cr at 4 • OWNER=BUILDER DECLARATION
INFORMATION
MISC.- REFER TO ORD
w 3 u y 1 hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
F .. O 4 Law for the following reason(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 10.00
is I Code:Any city or county which requires a permit to construct.alter, �!-���
2 ¢ ¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEG. J
da
- DLL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
u w m m he is licensed Pursuant to the provisions of the Contractor's License
>
Law(Chapter 9(cun,mencingw'ith Section 7000)of Division 3o fthe
r 4 ]justness and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE ICIA6
¢ I, Do the hasis for life alleged exemption.Any violation of Sect on 7031.5 'STORIES - TYPE CONSTR.
by any applicant lura pemhit subjects the applicant to a civil penully ALTER-DRAIN&VENT-WATER IEA.) 5.00
of Int more than five hundred dollars(S500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 oCe.GROUP RES.UNITS
sole compensation,will do the work,and the structure R not
intended or offered for sale(Sea 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 F IXTUR ES-PER TRAP 5.00 SO.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such inq...se
ments are not intended or offered for sale.if,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
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-
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 1:1 IND ElEl❑ 1,as owner of thty,
e proper ,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 contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL N0.
❑ I din exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Dote WATER SYSTEM' 5.00
ACC.DATE ACC.FILE NO,
WORKERS'COMPEN'SATION DECLARATION WATER TREATING EQUIP. 5.00
I mo,lby affirm that I hire.a certificate of consent to self-insure. ZONING
or u eerlifieate of Workers'Compensat}yyyyypsss��n Insurance,or a certified ENG.SITE NO.
arty thereof lSec.3800,Lub.G
' Policy No. - ompany .0q later
Q ❑ Ccrtilicdc y'i hereby ISO FIRE SPRINK ENERGY L24
z ❑ Certified o is fl wit he ty inspection division. MISC.- REFER TO ORD.
Z
Applicant - Y ❑ N❑ Y ❑ No
T CERTI JG1TIi01'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU > COMPFNSA'TION INSURANCE PLG.CONTR. LIC.NO, PLG. Y� N� v � N�
Z (This section need not be completed if the permit is for one TOTAL
hundred dollars IS 100)or I"x')
U O I certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
U n Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOlIC17 '10 APPLICANT: If,after making this Certificate of lix-
I.-. Z ..prion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK �7 ii
provisions of the Labor Code, you must forthwith comply with FEE / 3
y- U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONST RUCTION LENDING AGENCY AIR HANDLING UNITIOVER 10=C.F.M.) 6.00 SEISMIC FEE
1 hereby affirm tat there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the perfurinanee of the work fir which this permit is issued(Sec. MICROFILM
3097.Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Addi HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I cL,tity mm I line,read this application and state than the above VENTILATION FAN (SINGLE) 4.00
it lorn atiou is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby arhorize representatives of this city to enter upon the BOILER-COMP (Over 100.000 STU)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 liahilitur - figments, costs and expenses which CONST.TAX
may i y way Code gmnst said City in consequence of the PERMIT ISSUANCE 10.00
grant g this p rt. MECH.CONT. LIG NO. MECH.
11 TOTAL TOTAL -3&
Si turcof pplic o f
/ rac Date
INSPECTOR COPY