9060 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTI ICATION - PEHMITNVMBERR
BUIEDINGADDRESS ,f FE APPLICATION & PERMIT - 9060
UILDING - ELECTRICAL-PLUMBING-MECHANICAL
Ow E PLAN CHECK VALIDATION
N M OTV. ELECTRIC PERMIT FEE
• CONTRACTOR'S �( 33 UTLETS-SWITCHES-RECEP 10.00/1.00 -'
E ,�ASC- .0 J LIGHTING FIXTURES 10.00/1,00
ADDRESS oRPPLIANCES-RESIDENTIAL 4.00
CONTRACTORS
JJB�� v 10 PANELS 10.00 DATE OF APPLICATION
AOF Tecr PANELS (OVER 200 AMP) 20.00 ' PLAN CHECK FEE P.C.NO.
ENGINEER
uc.NO SIGNS TRANS. 3,00
ADDHESs ENa. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE 20.00
AANrs MOTORS ADDRESS �NFEE SCH.
/s
{�
SERVICECHANGE 20.00 `�
w w o LICENSED CONTRACTORS DECLARATION TEMP.POLE .+ 30.00 �0 PP
E,to I hereby affirm that I am licensed under provisions of Chapter 9 s ISSUANCE DATE
y w (commencing with Section 7000)of Division 3 of the Business and
III O is a Q )""'� � I BLDG. EL PL❑G. MECH.
z Professions Code G-�,n�d�,r9y 'cense is in full far d
z o y- License Chyyyg����sy, Lic.Number E
w t-w
Date
Contractor Ct�
ac M s BUILDING PERMIT
M OWNER-BUILDER DB I. RA I I INFORMATION
w ; ` H 1 hereby affirm that I am exempt from the Contractor's License M C.- REFER TO ORD VALUATION
Hw0 J Law for the followingreason.(Sec.703 1.5,Businessand Professions PERMITISSU CE 10.00 SIFT,
,;vi Cade:Any city or county which requires a permit to const ruct,alter,
le ¢ a FO improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.N0, ELEC.
O u requires the applicant for such permit to file a signed statement Ihat TOTAL 3d PERMIT TO
n 2 he is licensed pursuant to the provisions of the Contrmtor's License -
Vazi Lxw(Chapter 9(commencing with Section 7000)of Division 3 of the
a Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR,
i ; - by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500).1:
❑ 1,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 sl ration,is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,GOND. 5.00
Code:The Contractor's License Law does not apply to an owner of
properly who builds or Improves themon,and who does such work FIXTURES-PER TRAP 5.00 $D,FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees.Provided that such imPrmc-
meitsarenotintended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 IEA) 200
builder will have the burden of proving that he did not build or I'll- - . - . .
- BUILDING USE
prove for Purpose of sale.). INDUSTRIAL WASTE INTER. '30.00 RES IND CON PB orher
❑ I,as owner of the properly,am exclusively contracting with '❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code,The Contractor's License Law dues not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contractofs)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
file Contractor's License Law. TRACT NO, PARCEL NO.
❑ I am exempt under Sec.-,B&P.C.for this WATER HEATER W/VENT 6.00
music"
Owner Dale WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
'ycy�CrrF'.�,$'f MM ATION WATER TREATING EOUIP.^ 5.00
I e a lr fTg• I I(n(tc aLL nI mself-insure. - ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
Copy thereof(SVC.3800,Lab.C.)
Policy No.
rt is ITeb y__I�/_�
Q ❑ Certified copy lest EIV ford sl et. FIRE SPRINK ENERGY T-24
Z Z andCe' filed al ms Ilion division. MISC.- REFER TO ORD.
O AP leant- Y❑ N❑ Y ❑ N❑
y CERTIFICATE OFF: PTION WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU COMPEN.ATION INS ANCH - PLG.CONTE, LIC.N0, PLG.
Z (This seclion need not he completed if the permit is for one TOTAL Y[:] N❑ Y❑ N❑
hundred dollars IS 100)or less.)
U 0 1 certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL mit is issued,I shall not employ any Person in any manner so as to
Ow becomesubjecl to the Workers'Compensation Laws of California.
n Date ApplicantBUILDING
>_ En NO'T'ICE TO APPLICANT': If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
F. 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
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,00DC.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 IWITH DUCT) 5.00
the performance of the work for hich this permit Is Issued(SVC. MICROFILM
3097,Civ C.). ' HEATING UNIT ITO 100,000 B.T.U.) 8.00
Leader's Name
Lender's Address HEATING UNIT(OVER 100,000B.T.U.)9.50 ELECTRIC
1 certify that 1 have read this application andstole that the above VENTILATION FAN (SINGLE) 4.00
• information is correct. I agree to comply with oil city and county PLUMBING
ordinances and state laws relating to building u
construction, BOILER-COMP(3 H.P.Or 100,0008.T.U.) 6.00
hereby authorize representatives of this city to enter upon thnJe BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property.for inspection purposes.
(We) agree to save; indemnify and keep larmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in an w ucerue'agai t sail City in onsequcnee of the
gra Ilf ml[ MECH.CONT. LIC.NO. MECH.
�- TOTAL TOTAL
8' reol`Ap man o RlClor 7Dute
' / OFFICE COPY -