9053 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PRO PERMIT NUMBER T I ENTIFICATION APPLICATION & PERMIT
BUILDING
AooRsBUILDING —ELECTRICAL—PLUMBING—MECHANICAL 9053 Or3 pa ) X
OWNER'S - PLAN CHECK VALIDATION
NAM — QTY. ELECTRIC PERMIT FEE
OrvE
NOMrRACTans /, UTLETS-S I CHES-RECEP 10.00/1.00
£D,L,'00 r l ND. LIGHTING FIXTURES 10.00/1.00
-DADDRESS NTRACTORs PPLIANCES-RESIDENTIAL 4.00
PANELS 10.00 DATE OF APPLICATION
AARRCHITECT u PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.L.NO.
O
ENGINEER I.C. //LL�
c.No. SIGNS TRANS. 3.00 GA�Q
ARCH,OR ENG. PERMIT VALIDATION
AnORESS SPECIAL CIRCUIT 5.00 e
ZIP EMP.METER OR POLE INS. 20.00 AY aL�E7
APPL
AP LRANTS MOTOR SEE FEE SCH.
SERVICE CHANGE 20.00 CRY.d CUY-°'�rnd
Ci o LICENSED CONTRACTORS DEC LARATIONI TEMP.POLE 30.00
a u u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
1- w (commencing with Section 7000)of Division 3 of the Business and
a¢ n BLDG. T. PLG. MECH.
r N i Professions CoJ an y license is in full fore and f• t
o i w o Licen. vs Lac.Number - E
r w Oute Contractor
< x f BI LDING PERMIT ,.
¢ c ¢ OWNI:R-BUILDER DECLARATION
o s u NFORMATION'
w3 w w 1 hereby affirm that I am exempt from the Contractor's License MISC.— _ UI U REFER TO ORD
a, I-aw far the fallowing reason.(Sec.7031.1,Businessaol Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
Code:Any city or county whichrequiresa Permit to construct,alter,
EE
ve¢ o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
D u requires the applicant for such permit to file a signed statement that TOTAL PE IT TO /
A w$ he is licensed pursuant to the provisions ol'the Contractor's License
Hit Law Chapter 9(commencing with Section 7000)ofDivision 3 of the
¢ Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE'
2 Lc-m the basis for the alleged Exemption.Any violation of Section 7031.5 STORI 5 TYPE OONSTR.
. ': by any applicant for a permit subjects the applicant to a cavil penalty ALTER-TER -WATER (EA.) 5.00 .
of mol more than five hundred dollars(8500)):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5,DD SO.FT,FLOOR AREA TOTAL ACREAGE
himselfor through his own employees,provided that such ampmve-
mentsare not intended orofferedfor sale.if.however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00
or 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 dirt not build or im. BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON- PB Oma,
❑ I,as owner of the property,am exclusively contracting with 1:1 ❑ ❑ D ❑
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 contmctnrfs)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200tt/10.00 TRACT NO. PARCEL NO.
❑ Ism exempt under Sec.—,HAP.C.for this
WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COM PENSA'I'ION UI:CLA RATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofconwnt to self-insure.
or a certificate of Workers'Compensaliyn In urance t r u ri fieit ZONING ENG.SITE NO.
copy thereof Sec.3800,Lab-C 'Y
Policy No. Company -
Q ❑ Certified copy ishereby furnished. FIRESPRINK ENERGYT-24
Z Z U Cerlifaed coM.is tiled wit lu-Ble Mlv inspection division.
0 Applicant v�LL..tt LC a 4S�%G -.� MISC.- REFER TO ORD. Y N❑ Y [3 NE]
~ va u t PERMIT ISSUANCE 10.00
LU — CI3RTIPICCOMOPIATION INS PROMWORKIiRS' PLOOO ZONE A.L.U.C.
W � COMPF,NSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
CL Z This section meet[ not be completed if the permit is for one TOTAL V❑ N V ❑ N�
hundred dollars IS 100)or less.)
U 0 1 certify that in the performance of the work for which this per. DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL h mil is issued, I shall not employ any person in any mannerso as to
0 Ed becomes lac to t ne Workers Cpmpensuti0 �, of Ca 'orris.
Date pplicant .4tx, �rn7 t-�— BUILDING
} W NOTICE APPLICANT: If,alter making this Certificate of fix ALTER OR ADD TO MECH. 5.00
rZ 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 of this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is u construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
1 certify that I have Lad this application and stale 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-COMPI3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purpoBOILER-COMP (Over 100,000 BTU)BEE FEE SCH. MECHANICAL
ses.
(WC) agree to save, indemnify and keep hmmless 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 against mid City in consequence of the
granting of this permit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signature of Applicant/Contractor Uam
OFFICE COPY