9037 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
' _ PERMITNUMBER
BUILDING PROJECT � APPLICATION Bl PERMIT
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BUILDING Jj ��,(J
Ow ERS PLAN CHECK VALIDATION
• N E QTY. -ELECTRIC PERMIT FEE
PHONE
A TOR'S
NA � 4 OUTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
CONTRACT 'S
ADDRESS z8y 5vw/ APPLIANCES-RESIDENTIAL 4.00
17
PHONE PANELS 10.00
GATE OF APPLICATION
ARCHITECT HI CT PANELS (OVER200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
POP TEMP. METER OR POLE INS. 20.00 A
APPLICANT'S MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 d' ,
,0 o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 C� ^` ^ 19a
a o w .1 hereby affirm that I am licensed under provisions of Chapter 9 �Q5 E DATE
as a w e im"Ormg with Section 7000)of Divislmt 3 of the Business and BLDG. EL MECH.
r o z Professions CodyyyanI�dy cense is in full furyy�pyp�� 107
❑ ❑ ❑
o0 a LicenseCI����SSSSSSsl.�yi. Lic.NumberyY7�
DateB�'Q/ Contractor/�-
¢ yE � v✓ f(// I✓
¢ ¢ w a OWNER-B UILUER DECLA RAT NRI YY BUILDING.P RMIT }
a o A U I INFORM ION
X ; LL I- 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
U. U. Law for the followingreason,(Sec.7031.5,IiusinessanJ Professions VALUATION 5/FT.
- 'PERMIT ISSUANCE 10.00
Code:Any city or county which requiresa permit to construct,alter,
¢ ¢ a 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
e. m¢ requires the applicant for such permit to file a signed statement that TOTAL
u w he is licensed pursuant to the provisions of the Contractor'sLicense -,PERMIT TO
H z < Law(Chapter9(commencing with Section 7000)of Division 30T lh e -
4 o Business and Professions Code)or that he isexempt therefrom and OTV. PLUMBING PERMIT FEE
IS I-c� the basis for the alleged exemption.Any violation of Section 7031.5 ST RIES TV E CONSTR.
A„ - by any applicant for a permit subjects the applicant tuacivil penalty gLTER-DRAIN&VENT-WATEfl (EA.) 5.00
of not atone than five hundred dollars fS5001.):
❑ I,as Owner of the property,or my employees with wages as BACK FLOW ROTECT. DEVICE 4.00 OCE.GROUP ES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions 6RAIN LOO ROOF,AR EA,CON D. 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 FIXTURE -PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees,provided that such improve
or improvemehotnt
or within
red one or year
I completion
the theo nee- GAS-EA.SYSTEM-1INC.40UTLETS 6.00
or improvement is sold within one year of c0mdid on, the o r im-
buildcr will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILD N USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER 0.00 RES IND PB Other
❑ I,as owner of the property,am exclusively contracting with [3 EJ EJ Ej
licensed contractors ID construct the project (Sec.7044,Bminess LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSOR PA CEL NO.
and Professions Code:The 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 contractor(s)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.I'or this WATER HEATER W/VENT .00
mason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK H RS'COM PENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation losty'ance,or a certified ZONING ENG.SITE N0.
copy lher ( 0 ah 1 g
O Polic gi�I j�=
rD copy isoler-cby onrush
Z Z Certi ( t speCY n division. FIRE SPRINK ENERGY TQ9
N 0 p icnnt �� MISC.- REFER TO ORD. y � N❑ v ❑ rv�
cc CH RTI 1:1 CATE O F Ii XEM I'1ION F ROM WO R K E RS' PERMIT ISSUANCE 10.00' FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
CL O (This section need not he completed if the permit is for one TOTA Y N V I] N
::) Z hundred dollars IS 100)or less)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
IL I- mit is issued,1 shall not employ any person in any mannerso as to
0 W omesubjecttotheWorkers'CompcnseionLawsofCulilornia'
y BUILDING Date Applicant ALTER OR ADD TO MECH. 5.00
>_ W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F Z eruption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply will,U FEE such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 4,00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I herchy affirm that Gere is a Construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(See. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATI NG UN IT(OVER 100,000 B.T.U.)9.50 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-CDMP(3 H.P.or 100,000 B.T.U.) 6.00
herchy in-entioed roperty forves
inspection
ois city to enter upon the BOILER-COMP(over 100,000BTUISEE FEESCH. MECHANICAL
above-mentioned properly forinsp ofth i purposes.
(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 wvay accrue again m City in consequence of the
gra- -
' his L MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL '
/V Si n Ic nt C tr Eton ate
OFFICE COPY