9224 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
BUILDINGPLAN9224OWNER' - PLAN CHECK VALIDATION
I
"AME OTY. ELECTRIC PERMIT FEE'1 PHONE 1 `7�I /`
CONTRACTORS OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME
LIC.NO, LIGHTING FIXTURES 10.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENGSPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS. 20.00 t
ASMOTORS SEE FEE SCH.
ADDREDDRESSS
SERVICE CHANGE 20.00
o¢z
,00 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 '�
< u. I hereby affirm that I am licensed under Provisions of Chapter 9 ISSUANCE DATE
v, <w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H w z Professions Code,and my license is in full force and effect. ❑ ❑ ❑ ❑
License Class Lia Number-
4 zm- uoDam Contractor
a m BUILDING PERMIT
¢ a OWNER-BUILDER D17CLARATION
E oa" MISC. REFER TO ORD INFORMATION
K ; ¢y I heroby al}7nn Ont I con exempt from the Conlmctor's License VALUATION $/FT.
H u 0 4 Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 10.00
o Code:Anycity orcounty which requires a permit to construct,alter, --yar��
¢ ¢¢ 0 Improve,demolish,or repair any Structure,prior to Its Issuance,also ELEC.CONTR. LIC.NO. ELEC. wQ W
- 0 ¢- requires Dn applicant for such permit to Ili ca signed statement that TOTAL
u w w y he is licensed pursuant to the provisions of the Contractors License PERMIT TO
Fz > Law(Chapter9(Commencing with Section 7000)of Division 3 ofthe
4 Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE A i A/r, (WA4-
¢ r mthe basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a3 _ by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ L as owner of the property or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered 1'or sale (Sea 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,CON D. 5.00
Code:The Contractors License,Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SQ.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees.Provided that such'"'prove-
meetsareButintendedorofferedforcale.If,however,the building GAS-EA.SV$TEM-11NC.40UTLETS 6.00
or improvement Is sold within Beayear of completion, the owner GAS-EASYSTEM-OVER 4(EA.) 200 BUILDING USE
builder will have the burden of proving that h . . .
e did not build or im- RES IND CON PD Omer
for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 1,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,License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EAI 1.00
contracts for such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ Iwnexemprunder Sec. B.&P.C.I...this WATER HEATER W/VENT 6.00
reason
ownerDare'; WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMP ENSATI ON :C LARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure. '-tis ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(See.3800,Lab.CJ.
Policy No. Company
O O Certified copy is hereby l dum,lal. FIRE SPRINK ENERGY T-24
Z 2 ❑ Certified copy is fled with the city inspection division.
O Applicant MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
I W CERTIFICATE 01'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. v❑ N❑ v[:] N❑
CL 0 (This section need not be completed if the permit is for one TOTAL
hundred dollars($1001 or less.)
U 0 1 certify that in the performance of[lie work lin which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any person in any manner so as to
V become subject to the Workers'Compensation Laws of California.
U Lu Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>_ W NOTICE'1'0 API'LICAN"r: If,after making till,Certificate of Ex-
I Z_ emption,you should become subject to file 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 10)000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE a-U
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
tire 3097,Civ.0 ante of the work for which this permit is issued(Sec. MICROFILM
HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certily that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• information is correct, 1 agree to comply with all city and countyPLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3H.P.or100,000B.T.U.) 6.00
bereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
(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 ace against 'id City in consequence of the
granting o f this p•r MECH.CONT. LIG NO, MECH.
TOTAL TOTAL Q S�
S ah of pplicant/Contruc r - a /
INSPECTOR COPY