10062 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
. BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
_7L ADDRESS
APPLICATION & PERMIT 1 OO6Z
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMITTEE
PXON
NAMERACT 's ( UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.No. LIGHTING FIXTURES 10.00/1.00
ADDRESS APPLIANCES PPLIANCES-RESIDENTIAL 4.00
CONTRACTOR'S
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHIT
PANELS (OVER 200 AMPI 20.60 PLAN CHECK FEE P.C.NO.
GI FSR
LIC.Na SIGNS TRANS. 3.00
ADDRESS ENG' SPECIALCIFICUIT 5,00 PERMIT VALIDATION
Snf. Zip ogm TEMP.METER OR POLE INS. 20.00
APPLICANT'S MOTORS SEE FEE SCH.
ADOR ESS
$(j SERVICE CHANGE 20.00
00 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 //v / • S
Fi w , I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w a a (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. I PLG. MECH.
H 0 i Professions Code,and my license is in full force and effect. El ❑ 11 ❑
as 0 4 - License Class Lic.Number
D zz ;w Date Contractor
a m s d - BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DECLARATION
Eos 0 _ INFORMATION
X ; v"i I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION S/FT.
. " u 0 J Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Fw0f Code:Anycity orcounty which requires a permit to construct,alter,
¢ ¢ a O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. $LEC.
y W m LL
requires the applicant for such permit to(lie a Signed statement that TOTAL PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License
FiQ Law(Chapter9(commencing with Section 7000)of Division3 ofthe �/t-fO-L(s{�y /AlyrjQ/
Mi 0 Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢1- the basis for the alleged exemption.Any violation tto.clion malty STORIES TYPE CONSTR.
by any applicant for hemi subjects $500).licanttoacivil pene0y ALTER-DRAIN -WATER (EA.) 5.00
of not more Than five hundred dollars(5500).):
0 I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
(heir Sale compensation,will do the work,and the sl ruclure is not OCC.GROUP RES.UNITS
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
properly who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.66 SO FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedoro(fered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,(he owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Our.,
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors m 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 docs 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 contractorfs)'licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,B&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Dote WATER SYSTEM 5.00 ACC.DATE - ACC.FILE NO.
WORKI:RS'COMPCNSA'I'ION DECLARATION WATER TREATING EQUIP. 5.00 -
I hereby affirm that I have a certificate of cnnscut to self-insure, J ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,L.b.C.).
Policy No. • Company
Q ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T.2a
Z Z 0 Certified copy is fled with the city inspection division. MISC.- REFER TO ORD.
O Applicant V❑ N❑ Y ❑ N❑
~ na
CE
LU - RTI FICCOIi
EXEMPTION FROM WORKERS' FLOOD ZONE A. U.C.
W > COMPEH PERMIT ISSUANCE 10.00 L
NSATION INSURANCEPLG.CONTR. LIC.NO. PLG.
1 a (This section need no( be completed if the Penn it is for one TOTAL Y E] N❑ Y [:] N❑
:) Z hundred dollars($100)orless.)
U O 1 certify that in the performance of the work for which this per- QTY. - MECHANICAL PERMIT FEE FEE SUMMARY s
LL I- mi(is issued,I shall not employ any person in any manner so as to
O w become subject to the Workers'Compensation Laws of California.
B, Data Applicant ALTER OR ADD TO MECH. 5.00 BUILDING S�
} N NOTICE:TO APPLICANT: If,after making this Certificate of Ex-
F ? emption,you should become subject to the workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of (he Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10X0 C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10A60 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(Sea MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name H EATI NG UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I 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 county PLUMBING
ordinances and state laws relating.to building construction, and BOILER-COMP I3 H.P.Of 100,000 B.T.U.) 6.00
hereby authorise representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property 1'or inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,jud ms, costs and expenses which ,PERMIT ISSUANCE 10.00 CONST.TAX
may i at accrue agar aid City In co equence of the
gr ng o tis pernlit. 2 H,CONT. LIC.NO. MECH.
old
gnalure o Applican Contractor Uale ./ TOTAL TOTAL 47
- OFFICE COPY
' a