8205 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY ^
.-BU I LDING PROJECT I DENT]FICATI ON PERMIT NUMBER
e6lL 1.DING APPLICATION & PERMIT
ry 1� NDOR ESS
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNS '5 PLAN CHECK VALIDATION
NAME /j QTY. ELECTRIC PERMIT FEE
GNrJ -0700
"°MER.5UPP?/04 qul'o- OUTLETS-SWITCHES-RECEP 10.00/1.00
D /AJL p LC.NO. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
R's
ADDRESS
75� - APPLIANCES-RESIDENTIAL 4.00
7
Wa PANELS 10.00 DATE OF APPLICATION
ARCHITECT
OR PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.No.
ENGINEER
' uc.NO. SIGNS TRANS. 3.00
ADDRESS ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP- TEMP.METER OR POLE INS. 20.00
APPLI
ADDRESS MOTORS SEE FEE SCH.
KESS Ess
--` - SERVICE CHANGE 20.00
0 0 o LICENSED("ON'FRACTORS DECLARATION TEMP.POLE 30.00 ,.1
sc v 1 hereby affirm that 1 am licensed under provisions of Chapter 9 � ISSUANCE DATE
ez w (commencing with Section 7000)of Division 3 of the Business'and
Q H BLDG. ELECT. PLG. MECH.
H D z Professions Code,and my license is in full force and effect. ❑ ❑ ❑ ❑
z zo w License Class,
9 H Date �Contructor
Y BUILDING PERMIT
rc ¢ a OWNERTUILDER DECLARATION
rl o d u , INFORMATION
w
3 LL w I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
a- < Law for the Fallowing realms.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
Code.Any city or county which requires a permit m construct.alter,
a- 0 improve,demolish,or repair any structure,prior to its issuance,oleo ELEC.CONTR. LIC.NO. ELEC.
iE O u requires lite applicant for such permit to file a signed statement that - TOTAL PERMIT TO
E
m he is licensed 9(copursuant to(commencing
provisions of the Contractor's License - p
Hie
Law(Chapterand
Profession,
Code)or
is exempt
and
a Business and Professions Code)or that is exempt therefrom and QTY. PLUMBING PERMIT FEE Ar
the basis for the alleged exemption.An violation of Section 7031.5 B B T NSTR,
La
La F m g pion. y
ate _ by any applicant for u permit subjects the applicant o a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
' of not more than five hundred dollars(5500).):
❑ 1,as owner of the property,or my employees with wages as 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,GOND. 5.00
Code:The Contractor's License Law docs not apply to an owner of a e
property who builds or improves thereon,and who does such work FIXTUfTES='PER TRAP✓ .5.00 SG.FT,FLOOR AREA TOTAL ACREAGE
S himself or through his own employers.Provided that such improve- -
meets are not intended 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(EA ) 2.00
builder will have the burden of proving that he did not build or ire - . .
- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON pe Omer
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ Ellicensed contractors to construct the Project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSo SPARCELNO.
and Professions Code:'fhe 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 forsuch projects with a contractors)licensed mrSoatt to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,K&P,C.I'..this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE N0.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure.
Or a Certificate of Worker,'Compensat Insurance,or a certified ZONING ENG.SITE NO.
Poloyt�ys�f�! 7f�.c.)- - - G
cu o rpany_ /
O 0 Certified copy is hereby to Fished. FIRE SPRINK ENERGY T-24
Z Z 0CerNfieq y i Hit the Y inslmetion division.
O ApPlicant MISC.- REFERTOORD. /r Y ❑ N❑J Y ❑ N❑
cc y (iXTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE'.q' A.L.U.C./
W COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. f
CL a( This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ NE]N
hundred dollars(5 100)or less I
U O I certify that in the performance of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL H mil is issued,1 shall not employ any person in any manner so as to
UU become subject to the Workers'Compensation Laws of California.
UJ Date Applicant BUILDING
} W NOTIC17 TO APPLICANT: If,after making this Certificate of Fix- ALTER OR ADD TO MECH. 5.00
Z emphon,you should become subject to the workers'Compensation APPLIANCE 5.00 PLAN CHECK p
P Of the Labor Code, you must forthwith romply with FEE ', fJ
U such provisions or this permit shall he dem8
deemed revoked. AIR HANDLING UNIT(TO 10/000C.F.M.) 4.00 '
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F,M.) 6.00 SEISMIC FEE r�
- 1 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.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Larder's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify thot I have read this application and ,at,that the above VENTILATION FAN (SINGLE) 4.00
infornatiou is correct, I agree to comply with all city and county PL-UMBING
ordinances and state laws relating to building construction, and BOILER-COUP(3 H.P.or 100,000 B.T.U.) 6.00
hereby amhoriee 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 harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
nsay in any way.accrue against said City in corset uence of the
gra Of this mit MECH.CONT. LIG NO. MECH.
TOTAL TOTAL
tefelot Applicant/Contractor Date
INSPECTOR COPY
- I
II