9269 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTI FICAT APPLICATION & PER PERMIT NUMBER
BUILDING
B NG-ELECTRICAL-PLUMBING-MECHANICA€ / 9269
wt RS PLAN CHECK VALIDATION
"AME QTY. ELECTRIC PERMIT FEE
HONE
gCONCTDRs OUTLETS-SWITCHES-RECEP 10.00/1.00
Llc.ry LIGHTING FIXTURES 10.00/1.00CTORSAPPLIANCES-RESIDENTIAL 4.00 S
` PHONE PANELS 10.00 TE OF APPLICATION
ARCHITECT - PANELS (OVER 200 AMP) 20.00 CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.oR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP rrEMP.METER OR POLE INS. 20.00 FjAJD
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 JUL
12 w o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 109''1058p5
a v 1 hereby affirm that I am licensed under provisions of Chapter 9 T
vHi a m (commencing with Section 7000)of Division 3 of the Business and BLDG. E MECH.
H w z Professions Co .and cense is in full fo r f� �� ❑
o i m W License Clasra
s� -)ate-contractor
s,
a f BUILDING P RMIT
Ix w< OWNER-BUILDER DECLARATION INFORM TION
E: oA r MISC.- REFER TO ORD
u n I hereby affirm that I am exempt from the Contractor's License VALUATION /FT.
HUN J Law for the following reason(Sec.7031.5.Businrssand Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requiresa permit to construct,alter,
Qp improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
g c u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
n w m m he is licensed pursuant to the provisions of the Contractor's License
Hz> Law(Chapter 9(commencing with Section 7000)of Division 3 of the
- a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
r o the basis for the alleged exemption.Any violation of-Section 7031.5 S ORI S TYPE CONSTR.
dam by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars(S500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCG 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,AR EA,COND. 5.00
Code:The Contractor's 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 50,FT.FLOOR AREA TOTAL ACREAGE
• himself re through his own employees, le.If.h.Rol such int building
ments ton through
intendeughhis or employeeffered for salc.lf,ed that oche building GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
- d I
builder will have the burden of proving that he did not build or im-
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 IND cary PB omen
❑ I,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 gSSE$SORS PARCEL NO.
and Professions Code The Contractor's License Law does nut apply
to an owner of property who both)$or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant m SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ I am exempt under Sec. ,BAP.C.tort us WATER HEATER W/VENT 6.00 17,
Etas.,
owner Dae WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO,
WORKERS'COMPF.NSATION DECLARATION WATER TREATING EQUIP. 5.00
I hemhy affirm that I have o certificate of consent to Mtwiasure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a cerlif ted
copy thereof ISte.3800,Lab.CJ.
Policy No. Com ony
0 q Cfyytr it cd y Is h mnishod. FIRE SPRINK ENERGY T 24
Z Z Certif ct II c ly inspection division. MISC.- REFER TO ORD.
O Applicant- -,�'{'4-- Y ❑ N❑ Y ❑ No
CC W CERTIFICATE 01'EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 PLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTE. ❑O.NO. PLG. v❑ N❑ Y❑ N❑
Q. ❑ This section need not be completed if the permit is for one TOTAL
Z 1mmd,cJd.11ars(SI00)or If.)
U O 1 certify that in the performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
W H mit is issum
ed.I shall not eploy any person in ony manner so as to
U become subject to the Workers'Compensation Laws of Califontia.
U a
Date-Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>_ N. NOTICE TO APPLICANT: IL after making this Certificate of Ex.
? enlption,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 30=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10D=MC.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. 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 ELECTRIC
Lender's Address
I certify that 1 have lead this application and state 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-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP lover 100,000 BTU)SEE FEE SCH. MECHANICAL
abovementioned property for inspection purposes.
(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 iWwcntife aga.Lost mid City in consegl once of the PERMIT ISSUANCE 10.00
graMECH.CONT. LIC.NO. MECH.
� TOTAL TOTAL
S atontractor Uale
OFFICE COPY