11227 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE
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MIT NUMBER UMBER
BUILDING APPLICATION MT8U1LDING PROJECT IDENTIFICATION
ADDRESS MECHANICAL 1GG
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� BAll u
BUILDING -ELECTRICAL-PLUMBING-
OWNERS
PLAN CHECK VALIDATION
T NTaME E $1(i PNDNE 5 -
OTY. ELECTRIC PERMIT FEE
FIs u
/
CONTRACTORS
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.No, LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
Rs
ADDRESS
PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITfCrPANELS (OVER 200 AMP) 20.00 PLAN CHELK FFE P.C.NO.
OR
ENGINEER
' Lc.No. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 500 PERMIT VALIDATION
ADDRESS .
ZIP EMP.METER OR POLE INS. 20.00
APPLICANTS
ADDRESS MOTORS SEE FEE SCH.
-
- SERVICE CHANG 20.00 ot6l
woo LICENSED CONTRACTORS DECLARATION
¢u u I hereby affirm that 1 am licensed under provisions of Chapter 9 1 ISSUANCE DATE
y a n (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
w
H z Professions Code,and my license is in full force and effect ❑
io 0 w G License Class Lic.Number I ❑ ��/pslt ❑
Dale Contractor T-
¢ Y's BUILDING PERMIT
¢ ¢
If
u OWNER.BUILDER DECLARATION INFORMATION
w A F. I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
y VALUATION $/FT.
F IAog Law forthefollowimgrty which
reclines rosiness to
Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit Io construct,alter,
a ¢ ¢ G improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. 9 �y
D¢ requires the applicant for such permit to file a signed statement that TOTAL V Q PERMIT TO
A w m he is licensed pursuant to the provisions of tine Contractor's License � �
rzi Law(Chapter9(commencing with Section 7000)of Division 3 ofthe
et Business and Profusions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
IS r $ the basis for We alleged exemption.Any violation of Seclion703L5 STORIES TYPE CONSTR.
by any applicant fora permit subjects tire applicant loacivil penally ALTER-DRAIN St VENT-WATER (EA.) 5.00
of nal more than five hundred property,
o my employees
❑ Las owner at the property,Ur my employees with wage as BACK F LOW PROTECT. DEVICE 4.00
their Sed r offered
will(S the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CON D. 5.00 )
Code:The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 sD.Fr.FLOOR AREA TOTAL ACREAGE
mntahimself re through his own employees,sale,provided that such improve-
menlsarvcmintended or withinrone yearnIf,mpletion the the oning GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
Im improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the burden of-proving that he did not build or im- BUILDING USE
prove 1,as owner of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND0 0 Pe Omer
❑ d as owner of the property,and exclusively 7044.ting with ❑ ❑ ❑ ❑ ❑
licensed contractors to The
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 or properly who builds or improves thereon,and LAWN SPRINKLERS-OVER 5(EA.) 1.00
wntroCorsuchprojects with umntrlruc[orfs)licensed pursuantt to In SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam exeEu der Sc,_,_ B.&P.C.for this WATER HEATER W/VENT 6.00
/
Owner]B owner Date WATER SYSTEM 5.00 Ace.DATE ACC.FILE N0.
WORKERS'COMPENSA'PION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING
or a certificate of Workers'Compensation Insurance,ora certified ENG.SITE NO.
copy tl¢reof(Sec.3800,Lab.CJ.
Policy No. Company
0 ❑ Certified copy is hereby famished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with the city inspection division. MISC- REFER TO ORD.
O Applicant Y ❑ N❑ V [:JN❑
Fy PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.c.
LU CERTIFICATE E EXEMPTION FROM WORKERS'W � COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CIL O ('(his section need not be completed if the permit Is for one TOTAL Y❑ N❑ Y❑ N❑
D Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- OTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL 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.
L Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F Z 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
0 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4,00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE
I hereby aflinn thin there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
th3097 xCiv.0 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 HEATING UNIT(OVER 100,000 B.T.U.)9.50 3Q �y
Lender's Address ECTRIC
• I certify that I have read this application and slate that the shove VENTILATION FAN (SINGLE) 4.00
information is correct.1 agree to comply with all city and county PLUMBING
ordinances and stale 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 100,000 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,judg s, cosIS and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in a accrue agmns c J City in consequence of the
grantingoh ' Ter MECH.CONT. LIQ NO. MECH.
-0_8"G TOTAL TOTAL
Signature of Applicant/Contractor Date
OFFICE COPY