9268 APPLICANT TO FILL IN INFORMATION IN RED LINES - USE.BALL POINT PEN ONLY
_ PERMITNUMBER
BUILDING PROJECT IDENTIFICATIONI/CL/� APPLICATION & PERMIT
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DING-ELECTRICAL-PLUMBING-MECHANICAL
OWNERS PLAN CHECK VALIDATION
�� NAME QTY. ELECTRIC PERMIT FEE I
PHONE
N At TORS UTLETS-SWITCHES-RECEP 10.00/1.00
1 LIGHTING FIXTURES 10.00/1.00
ro Ac7oRs
SS
PPLIANCES-RESIDENTIAL 4.00
A° C l
•L• PHONE -LIZAPANELS 10.00 DATE OF APPLICATION
ogcwrecr PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO, SIGNS TRANS. 3.00 �
ADDR'ESSS ENGSPECIALCIRCUIT 5.00 IT VALIDATION
21P EMP.METER OR POLE INS. 20.00 UL 121985
APPucANrs MOTORS SEE FEE SCH.
AODAESS
SERVICE CHANGE 20.00 tY o1 Cupertitld
w w 2 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
FL,W I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
a n (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. I LG 11 MECH.
F N i Professions Code,and my license is in full force and effect. ❑ ❑ ❑
Z,i E W License Class Lic.Number
FNH J Date Contractor
a se s BUILDIN PERMIT
¢ ¢ ¢ OWNER-BUILDER DECLARATION
o n u INFO MATION
E
;u a 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
VALUATION
F u D J Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE - 10.00
i
Code:Any city or county which requires permit to construct,alter.
¢ ¢ a p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
wD ac requires the applicant for such permit to file a signed statement that TOTAL ERMIT TO
$N he is licensed pursuant to the provisions of the Contractor's License
Fi >
Law(Chapter 9(commenciagwith Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
Eic
¢s-$ the basis for the alleged exemption.Any violation of Section malty ST RIES TYPE CONSTR.
a ; by any applicant fora permit subjects tile ant toacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
o(not more than five hundred dollars(5500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
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,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 suds work FIXTURES-PER TRAP 5.00 a0.FT.FLOOR AREA TOTAL ACREAGE
• himsell'or through his own employees,provided that such improve.
mems are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im- IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 1,as owner of the properly,am exclusively contracting with ❑ ❑ ❑ ❑
• licensed contractors to construct fire 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
contrathe Coctsfor ctor'shceneLwilh aconlmdorfs)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
Ne Contractor's License Law.
❑ lam exempt under Sec.-.B.&P.C.]or this WATER HEATER W/VENT 6.00
reason
Owner [)ate WATER SYSTEM 5.00
ACC.DATE ACO.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure, - ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy.thereof(Sec.3800.LaQ.C.).
Policy No. Com Ly��Y'y -
C died iaf ished. FIRE SPR INK ENERGY T 24
Z ZO erhfie c f H/�Illj � inspection Division. MISC.- REFER TO ORD. ❑ ❑ ❑ ❑-
A cunt /�/E���� Y N V N
CCrn - PERMIT ISSUANCE 10.00 FLOODZONE A.LU.C.
W CER KATE F EXEMPTION FROM WORKERS'
W COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. / Y❑ N❑ Y❑ N❑
CL Z (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 performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
i Date ApplicantALTER OR ADD TO MECH. 5.00 BUILDING
> N NOTICE TO APPLICANT: If,after making this Certificate of Ex.
F 2
collation,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
Provisions of tire Labor,Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10l000C.RM.) 6.00 SEISMIC FEE
. I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
309 ,C'mC once of the work for which this permit is issued(Sea HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name
Lender's Address HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 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 m building construction, andmy 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 properly 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 sy ace against said City in consequen of the
go per MECH.CONT. LIC.NO. MECH;
xk& TOTAL _ TOTAL
S' lure pplicanl/Contractor U e
OFFICE COPY