10197 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENT&ICATIONPERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS 0 J[]
G_ELECTRICAL-PLUMBING-MECHANICAL
OWNER'5 PLAN CHECK VALIDATION
NAME
CU(.
ELECTRIC PERMIT FEE
• ON r.
CONTfl CT
NAME M
UTLETS-SWITCHES-RECEP 10.00/1.00
Llc. LIGHTING FIXTURES 10.00/1.00
CONT A R'S p ANCES-RESIDENTIAL 4.00
AOOR 5
1D �` AN S 10.00 DATE OF APPLICATION
ORcHlre T PA ELS(OVER 200 AMP) 20.00 PLAN CHECK FEE PC.ND.
ENGINEER
LE.No. SIGNS TRANS. 3.00
ARCH,OR
RESS ENG. SPECIALCIRCUIT 5,00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
ADDRESS
J
ASMOTORS SEE FEE SCH.
Cori
SERVICE CHANGE 20.00
o o
LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 ^^
< u I hereby affirm that I am licensed under provisions Of Chapter 9 PAIMANCE DATE
y<T (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH,
r ui Professions Code,an y license is in full force a ❑
o i 0 W License CI Lie.Number �i
L L Date Contractor
¢ "a a OWNER-BUILDER DECLARATION BUILDING PERMIT
X
;a. N I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD NATION;
FuoJ Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 A ION E/FT.
1w> Code:Any city or county which requires permit to construct,alter,
¢ ¢ e o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
A wG¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
m L he is licensed pursuant to the provisions of the Contractor's License -
H z a Law(Chapter 9(commencing with Section 7000)of Division 3 of the L-ElH .g/A/61-
q 4 o Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
¢r the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ 1,as owner of the property,or my employees with wages as - BACK FLOW PROTECT.DEVICE 4.00 Occ.GROUP REB.uNlis
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,CONE. 5.00
Code:The COmtraclor's License Law docs 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- GAS-EA.SVSTEM-11NC.40UTLETS 6.00
meets are not intended or offered for Sale.If,however,the building
or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 RES IND CON PB Other
C1 . .
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 5IEA.) 1,00
contracts the Contract suchLicense
ts Lwithacontractogsl licensed pursuant to SEWER-SANITARY-STORM EA.200tt/l0.00 TRACT NO, PARCEL NO,
the Contractor's License Law.
❑ I am exempt under Sec.-,BAP.C.for this 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
I hereby affirm that I have a certificate of consent loself-insure' ZONING ENG.SITE NO.
or ce "icare f Works C pen do sur: , r a rC ied
ora ny
it d 'o i he by urnis se .
Z Z ❑ Ti y s Ile wi th cit inspe lio d' 'FIRE SPRINK ENERGY T44
O App]' a MISC.- REFER TO ORD. v ❑ N Y ❑ N❑
~ w
C TIFICATEOF EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 FL000 zoNE A.L.U.C.
LU
UJ COMPENSATION INSURANCE pLG.cONTR. LIC.No. PLO.
CL Z( Thi section need not be completed if the permit is for one TOTAL YIN
Y E] N❑ Y C3 N[]
hundred dollars(S 100)or less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
IL U mit is issued,1 shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
y Date Applicant ALTER OR ADD TO MECH. 5,00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
? emption,you should become 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 10A000.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNITIOVER I0,000QRM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the 3097,Civ.C.)nce of the work for which this permit is issued IS". MICROFILM
UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certify that I have read this application and slate 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(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000BTU)SEE FEESCH. 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 CONST.TAX
By in any w accrue against Said City in cone en of the PERMIT ISSUANCE 10.OD
anling f t is iI ECH.CONT. LIC.NO. MECH.
TOTAL TOTAL /
nture (Applicant Con ctor Date ' C
OFFICE COPY