9351 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BVILOING APPLICATION & PERMIT
.T AooREss -
/t/�8 r BUILDING-ELECTRICAL-PLUMBING-MECHANICAL_ 9351
OWNER'S - PLAN CHECK VALIDATION
QTY. ELECTRIC PERMIT FEE
( '• J' iVl�i PHONE/ /�-/ F/
NAME ACTOR UTLETS-SWITCHES-RECEP 10.00/1.00
LIC_.NO. LIGHTING FIXTURES 10.00/1.00
ADDRESS
CToes APPLIANCES-RESIDENTIAL 4.00
CONTRA
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. ISIGNS TRANS. 3.00
ARC ess ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS /
SERVICE CHANGE 20.00 /4L✓
woo LICENSED CONT RACTORS DECLARATION TEMP.POLE 30.00 --71,L.`/
¢u 1 hereby affirm that I nm licensed under provisions of Chapter 9 ISSUANCE DATE
(erommencing with Section 7000)of Division 3 of the Business and
ri, a is, BLDG. ELECT. PLG. MECH.
r y z Professions Code,and,oy license is in full force and effect. El
❑Z O m - License Class Lie.Number
0 z r Date Contractor
a x f BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DECLARATION
S,
d u INFORMATION
w S LL 1 hereby al'lirrn that I am exempt from the Contractor's License MISC.- REFER TO ORD
u-Oa Law for the following reason,(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00 VALUATION SIFT.
Code:Any city orcounfy which requires a permit to construct,alter,
to
e, 4 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
- D u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
m
co he is licensed pursuant to the provisions of the Contractor's License
za
Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe �`�
i D Business and Professions Code)or that he is exempt therefrom and ATV. PLUMBING PERMIT FEE V-
¢ H e the basis for the alleged exemption.Any violation of SectioR703L5 STORIES TYPE CONSTR.
p3 � by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not moa than five hundred dollars(5500).):
❑ I,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 docs such work F IXTUR ES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTALACREAGE
• himself re through his own employees,for
le.If,cd that such improve
mems ore tot hrough his oro employees,provided
that such
ebuildie- GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement is sold within one year of completion the owner- GAS EASYSTEM OVER 4 IEA ) 200
builder will have the burden of proving that he did not build or ant- - . - .
- . BUILDING USE
Prov,for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ I,as owner of (lie property,am exclusively contracting with ❑ ❑ 0 0 0
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code: I'he 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 contmetorts)licensed pursuant to
the Contractor's License Law. It SEWER-SANITARY-STORM EA.200tt/10.00 rk TRACT NO. PARCEL NO.
El wn exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date" - WATER SYSTEM 5.00 ACC.DATE ace.FILE No.
WORK fiRS'COMPIiNSA' ION DECLARATION WATER TREATING EQUIP, 5.00
I hereby affirm that I have a certificate o fconsent toself-insum' ZONING or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.). i'
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y❑ N❑ Y ❑ N
� N CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 1_ 0 0--t- FLOOD 20NE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL0 (This section need not be completed if the permit is for one w TOTAL ,(moi Y.❑ N� V IN
U O hu ulmd dollars($100)or less.)
1 certify that In the performance of the work for which this per- OTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not crudity any person in any manner sous to
Ow beconm subject to the WosrkerCompensation Laws of California. BUILDING
a Dale Appire.t ALTER OR ADD TO MECH. 5.00 ,
•`} y NOTICE'10 APPLICANT': If,after making this Certificate of Es-
1F ? 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 10=C.F.M,) 4.00
CONS[RUC'I']ON LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sea MICROFILM
3097,G,CA HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lenders Name H EATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that 1 have read this application andstate 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 conslrneron, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 /•riG
hereby autllorire representatives of this city to enter upon the
above mentioned property for inspection purposes. BOILER-COMP(Over 100,000 BTU)SEE FEE BCH. 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 accrue against said City in consequence of the
B go(this permit MECH.CONT. LIG NO. MECH.
TOTAL TOTAL
' gnaturc I App I o U e
INSPECTOR COPY