9300 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON 7 PERMIT NUMBER
6UI1DING APPLICATION & PERMIT
ADDRESS
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 9300
WNEH'S /- PLAN CHECK VALIDATION
NAME - QTY. ELECTRIC PERMIT FEE
ONE
c m off OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME
uc.ND_ LIGHTING FIXTURES 10.00/1.00
T
ADDRESS Sl,.r,/tnU! APPLIANCES-RESIDENTIAL 4.00
Azi,_AAL 14 , 1 � �>✓ .
PHONE PANELS 10.00 DATE OF APPLICATION
ARCEfFECT PANELS 200 AMP) 20.00 PLAN CHECK FEE P.C.No.
DR '.
ENGINEER
uc.NO SIGNS TRANS. 3.00
ARC H.OR ENG. PER15V_A`IDATION
ID
ADDRESS SPECIALCIRCUIT 5.00
ZIP TEMP.METER OR POLE INS. 20.00
AREMOTORS SEE FEE SCH. JUL
ADDRESS
DDDDfl E55SS ]- G 5
SERVICE CHANGE 20.00 r�
'00 LICENSED CONTRACTORS DECLARA'TON TEMP.POLE 30.00 ' City Ot Cu
aI hereby a0ian that I am licensed under envisions of Cha to 9 PDATE
y Z 6 p s ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H ti z Professions Code.and cry license is in full Ibrcr and effect.
Z O m - License ClassQ Lte.Number
9 m DatcContructor
a se f / BU DING PERMIT
ar rc 'js, OWNER-BUILDER DECLARATION NFORMATION
X
a" � MISC.- REFER TO ORD
w ; a y I hereby a0inn that I am exempt front Hro Contractor's Lirense
a0Q Law for the following reaSan.(See.7031.5.Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
�- -' Code:Any City orcounly which requires a permit to construct,alter, _
2 ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC,NO ELEC.
- C, a: requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
wm a he is licensed pursuant to the provisions of the Contractor's License
HZQLaw(Chapter 9(commencing with Section 7000)of Division 3 ofthe ,
Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
SE the basis for the alleged exemption.Any violation of Section 7031.5 STO CONSTR.
a;m by any applicant for a permit subjects the applicant too civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more the.five hundred dollars(4500).1-
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCG GROUP RES.UNITS
their sole compensation,will do the work,and the structure is 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 FIXTURES-PER TRAP 5.00 SG.FT FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve
m0'ents arc not intended or offered for sale. ,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement Is sold within ane year of completion,the owner- GAS EASYSTEM-OVER 4 IEA) 200
builder will have the burden of - . . .
proving that he did not build or am- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 R,D CON PB Omer
❑ I,as owner of the property,am exclusively contracting with R ❑ ❑ ❑ ❑
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 docs 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 Contractor's License Law. / TRACTNO. PARCELNO.
❑ 1 am exempt under Sec. ,N.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACO.FILE NO,
WORKERS'COMPFNSA'TION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
ovcopy thereof(Sec 3800,Lab.C.).
Policy No. Company
❑ Certified copy is hereby famished. FIRE SPRINK ENERGY T24
Z Zy� Certifd copy is fled with he city inspection division. MISC. REFER TO ORD. ❑ ❑ ❑ N❑
AO APT licanl V N Y
CC w CERTIFICATE OF EXEMPT10N Fl h1 WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C.
L COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. v❑ N❑ V E] N❑
CL 0 (This section need not be completed if the permit is for one TOTAL _
hundred dollars IS 100)or less.)
U O 1 certify that in the pmformance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mil is issued. 1 shall not employ any person in any"runner so as to
O W become subject to the WorkersCompensation Laws of California BUILDING
0- Date npphcam ALTER OR ADD TO MECH. 5.00
} DO NOTICE 'FO APPLICANT: If,after making this Cerlificme of Ex-,
F Z_ emptio",you Should became subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
CJ such provisions or this permit Shall be deemed revoked. AIR HANDLING UNIT TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IO)000QF.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 -
tire cr.uman,c of the work for which this permit is issued(Ser. MICROFILM
UNIT (TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)Lender's Address ELECTRIC
I certify that l 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 slate laws relating to building construction, and BOILER-COMPO H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon lire 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
may in any way accrue u,pst said City in consequence of the
gra tiaOflhis permit MECH.CONT. LIG NO. MEOH.
TOTAL TOTAL
v{Contracted Date
INSPECTOR COPY