10000 (2) 1 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES - USE BALL POINT PEN ONLY
_I BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
T BUILOING APPLICATION & PERMIT 1 0000
AOORESS
0 BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME G /r •� .( CITY. ELECTRIC PERMIT FEE
k'IANAAMCONTRACTORsEEC/V& UTLETS-SWITCHES-RECEP 10.00/1.00
E r�� UC.No. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR
ORs PPLIANCES-RESIDENTIAL 4.00
CODNTRAS
PHONE PANELS 10.00 DATE OF APPLICATION
0gcerrscr PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE D.C.NO,
ENGINEER
Lm.No. ISIGNS TRANS. 3.00
ARCH.ss ENG. SPECIAL CIRCUIT $,QQ PERMIT VALIDATION
2IP EMP.METER OR POLE INS. 20.00 Pq�p
APPLICANTS MOTORS SEE FEE SCH. IYV
ADDRESS
V V " 4 Jfty
SERVICE CHANGE - 20.00 V
'09 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 /[Iy-Of
a v w I hereby affirm that I am licensed under provisions of Chapter 9 Y tUANP��O nO
w (commencing with Section 7000)of Division 3 of the Business and
a BLDG. ELECT. MECH.
0 i Professions Code,and my license is in full force and effect.
az ❑ ❑
W License Class Lin.Number
r m v_ J Date Contractor
a >! s BUILDIN ERMIT
a o o ° OWNER-BUILDER DECLARATION INFOR APER
X g;w w I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
aa,o J Law forthe followingreason,(Sec.7031.5,Businessand Professions PERMIT ISSUANCE- 1000 VALUATION $1FT.
m0 Code:Anycily orcounly which requimsa permit to construct,alter, .
40 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTH. LIC.NO. ELEC.
o u requires the applicant for such permit to file a signed statement that TOTAL MIT TO
w $w he is licensed pursuant to the provisions of the Contractor's License
a0 La. 9(commencing with Section 7000)ofDivision 3 ofthe
5 4 D Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
W 0 the basis for the alleged exemption.Any violation of Section703L5 STO IES TYPE CONSTR.
by any applicant for a permit subjects the applicant toacivilpenalty ALTER-DRAIN III VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500).1:
❑ I.as owner of the property,or my employees with wagesas BACK FLOW PROTECT.DEVICE 4.00
their sole compensation,will do the work,and the structure 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
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provi,ho that such improve-
mcntsarenotlnlendedoroffercdferSa provided
that s,the building GAS-EA:SYSTEM-1INC.4OUTLETS 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 h - . . .
e did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 INC CON PB Grow
❑ 1,as owner of the property,am exclusively contracting withIN) ❑ ❑ ❑ ❑
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 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 contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
DOam
actorS License Law. TRACT NO. PARCEL NO.
exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
DaterWATER SYSTEM. 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
y affirm that I have a certificate of consent to self-insure, ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.). _
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.
Q Applicant Y ❑ N❑ Y ❑ N❑
cr T CERTIFICATE OI'EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 tu, FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. y[:] N❑ v [:] N❑
tL Z (This section need not he completed if the permit is for one TOTAL v
hundred dollars($100)or less.)
U O I certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL P mil is issued,I Shall not employ any person in any manner so as to
(J become subject to the Workers Compensation Laws of California,
0. Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} so NOTICE TO APPLICANT: If,after making this Certificate of Ex-
I.. ? 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
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO l0J MOC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=11EM.) 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
HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)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 countyPLUMBING w
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 (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep hornless 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
granting of this er tl. MECH.CONT. LIC.NO. MECH.
✓ Y,,,r rr�y�.8�s- TOTAL TOTAL
Signatumof Applicant/Contractor
r Ume -
IOFFICE COPY