9441 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN"ONLY
PERMIT NUMBER
BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT
BDILDIND 94411
ADDRESS 7
OJZ C�Gh vyL BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
\ ' OWNER' 'J PLAN CHECK VALIDATION
Y NAME 1/ �] L QTY. ELECTRIC PERMIT FEE
PHONE Y�/ .
,•'
NOMELE
NrRAcroR's
NAOUTTSWITCHES-RECEP 10.00/1.00
LIC..No. LIGHTING F-SIXTURES 10.00/1.00
CONTRACTORS [APPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS - 10.00 DATE OF APPLICATION
RcwTEcr P.C.NO.
.' PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE -
O
OR
ENGINEER
uc,No. SIGNS TRANS. 3.00
ADDR.SS ENc. SPECIAUCIRCUIT 5.00 PERMIT VALIDATION .
ADDRESS '
ZIP TEMP.METER OR POLE INS. 20.00
APPucSa
ADDR EANTS
SEE FEE SCH. Q -W-•--•J
ADDR Ess f
SERVICE CHANGE_ • '20.00
ww o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
¢ f , f
M o u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
H G w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r D z Professions Code,and my license is in full force and effect. El ❑' ❑
z O ALicense Class Lie.Number
oZ I°u Date Contractor - BUILDING PE IT.
¢ ¢ w OWNER-BUILDER DECLARATION INFORMATION
F.
3 LL m 1 hereby affirm that I am"exempt from the Contractor's License MISC.- REFER TO ORD
r u VALUATION $/FT.
o er Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE . 10.00 -
Code:Any city property which requires a permit to construct,alter,
2 2¢Mimprove,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO.
O ELEC.
o LL requires the applicant for such permit to file a signed statement that TOTAL - PERMIT T°
A w m he is licensed pursuant to the provisions of the Contractor's License f�
r z i
Law(Chapter 9(commeneiagwith Section 7000)of Division 3 ofthe
s o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ I_ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant toacivil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(8500).):
❑ 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 Jo the work,and the structure is not -
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,CON D. 5.00
Code:The Contractor's License Law does not apply to an owner of -
S.00
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 'SO.FT.FLOOR AREA -TOTAL ACREAGE
himself through his own employees.provided that such improve-
ments
mes arere
not intended or offered for however,the building GAS-EA.SYSTEM-1 INC.4OUTLETS 8.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA,) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES . IND CON PS Other
prove for purpose of sale.). INDUSTRIAL WASTE INTE 30.00 El F-1 ❑ 1:1 11❑ I,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(See.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. Aa 00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply - 01) .
to an owner of property who builds or improves thereon.and who ILAWN SPRINKLERS `]5 PE ) "1l
contracts for such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/1 TRACT N0. PARCEL NO.
❑ I am exempt under See. ,B.&P.C.f.t this WATER HEATER W/VENLrjW Q .00
reason
Owner Date WATER SYSTEM -5.00 ACL.DATE ACC.FILE N0.
WORKERS'COMPF.NSATION 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,Lab.CJ.
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. y ❑ N❑ y E] N❑
O Applicant
LO CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE - A.L.D.C.
LU > COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG. /_ (� Y❑ N❑ v ❑ N❑
d O (This section need not be completed if the permit is for one TOTAL (O
Z hundred dollars($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 P mit is issued,1 shall not employ any person in any manner so as to
U beeome subject to the Workers'Compensation Laws of California. BUILDING
y Date Applicant - ALTER OR ADD TO MECH. 5.00
} N "NOTICE TO APPLICANT: If,after making this Certificate of Ex-
� 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
(� such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10DWC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 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(Sec. - HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.CJ.
'Lender's Name HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
1 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 countyPLUMBING
ordinances and state laws relating to building construction, and BOILER-00MP(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 FEE SCH, MECHANICAL
above-mentioned property for inspection purposes. '
h (We) agree to'save, indemnify and keep harmless the City of MISC.: REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses.which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
grant l}a6�of this p rtrnt. MECH.CONT. LIQ NO. MECH. '
/IN�G'L'Jic3/jc7/Grf
TOTAL TOTAL
Signatotte of Applicant Contractor Dade
OFFICE COPY _