8671 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY -
BUILDING PROJECT I DENTIFICATI ON PERMIT NUMBER
BU„DING APPLICATION & PERMIT /�
AOOREss (/
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
NAME PLAN NECK VALIDATI
^�M QTY. ELECTRIC PERMIT FEE
E EiI/
Na EA S UTLETS-SWITCHES-RECEP 1D,00/-1.00 \
LIC.NO,
LIGHTING FIXTURES 10.00/1.00 !
CONTRACTORS
oRs
ADDRESS PPLIANCES-RESIDENTIAL 4.00
l
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECTPLAN CHECK FEE
OR / PANELS (OVER 200 AMP( 20.00 ("-
' ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENc' SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS. 20.00
ADDRESS MOTORS SEE FEE SEH.
ADDRESS
SERVICE CHANGE 20.00
w
00 LICENSED CrONTRACTORS DECLARATION TEMP.POLEI 30.00
Q U u I hereby al(inn that I um licensed under provisions of Chapter 9 I ISSUANCE DATE
H i (commencing with Section 7000)of Division 3 of the Business and
¢ BLDG. ELECT. PLG. MECH.
r C i License Cla Codc,and my licahse is in full force and effect.
t O ui- License Class Lia Number
-
0
w Date Contractor
a m f BUILDING PERMIT
• ¢ w OWNER-BUILDER DECLARATION INFORMATION
E
LL I hereby affirm that I am exempt from the Contractor i License MISC.- REFER TO ORD VALUATION 5/FT.
Fw Oa Law for the following reason.(Sec.7031.5.dusinessand Professions PERMIT ISSUANCE 1 W
Code:Any city or county which requires a permit to construct,aheq
re R Q 0 improve,demolish,or repair any structure;prior to its issuan"a also ELEC.CONTR. LIC.NO" ELEC. /.
DLL requires the applicant for such permit to file a signed statement that TOTAL PEHMIT TO
w m he is licensed pursuant to the provisions of the Contractor's License
HZQ
Law(Chapmr9(commeneingwith Section 7000)of Division 3 of the /Nj•/?E'It-JD;�dL
Rosiness and Professions Code)or that he is esanpt therefrom and QTY. PLUMBING PERMIT FEE
ISIS- .. the basis for the alleged exemption.Any violation of Section 7031,5 STORIES C
u ; m by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my wel loyees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work.and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND-..5.00
•Code:The Contractor's License Law docs not apply to an owner u(
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself re through his own cmred lots provided that such improve-ding GAS-EA.SYSTEM-'1 INC.4 OUTLETS 6.00
meats are not intended oroffered
on lire sale.If,howmpleveq the bowne-
or improvement is sold within one year of completion.the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
huiv er will have the harden u(proving(hut he did not build or im- RES IND •CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ d as owner of the properly, o,exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed colons ode: I construct the priced(Sc, does Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 A55E550R5 PARCEL NO.
and Professions Code. ty Contractor's License law Joos not apply
In a owner of property who milds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
con acts(.,such projects with a contractods)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
c "obtiaator s License Law. TRACT N0. PARCEL N0.
:un exempt under Sec. ,B.&P.C.tier this WATER HEATER W/VENT 6.00
` re
6 er Date 4'!�. WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO,
3RS'COMY , ,TION DECLARATION✓/I , WATER TREATING EQUIP. 5.00
lhereby affirm that l have a certificate ofcunsent to se Ir-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certlfieA
copy thereof(Sec.3800,Lab.C.).
Policy No. ComPmry -
O ❑ Certified copy is hereby fumished. FIRE SPRINK ENERGY T"24
Z z ❑ Certified copy is fled with the city inspection division. MISC.- REFER TO ORD.
0 Applicant Y ❑ N❑ Y ❑ N❑
to C17RT1171CA'I'1:OF EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 FLDOD zDNE A.L.u.c.
LU �_ COhIPENN ATION INSURANCE PLG.CONTE. LIC.NO. PLG.
d 0 ('this section need not be completed if the permit is for one TOTAL v❑ 'N❑ V ❑L N❑
::) z hundred dollars($100)orIn,,J
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL:I- mit is issued,I shall not employ any person in any Firmer so as to
Ow become subject to the Workers'Compensation Laws of California.
a Data Applicant ALTER OR ADD TO MECH. 5.00 BUILDING O
�- m NOTICE 'f0 APPLI(' If,alter making this Cert ificute of nix- --
F 2 emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 a PLAN CHECK _
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions ovisns or this permit shall be deem00
ed revoked. AIR HANDLING NIT(TO 1OpC.F.M.) 4.00
CONST RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MOC.EM.) 6.00 SEISMIC FEE a/
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the peef...Ponce of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.CJ. H EATING UN IT(TO 100,000 B.T.U.) 8.00 �/
Lender's Name
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC 4 /
L
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
. intirrmation is correct. I agree to comply with all city and county PLUMBING
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 Ih
above-mentioned property for inspection purposes. a v
(We) agree to Save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
y any way neer agams said City in consequence of the PERMIT ISSUANCE 10.00
grantin fthis p rmi MECH.DONT" LIC.NO. MECH. �1
rorAL o2/ �i TOTAL of,'0 7/
Yn onLAW
1,- INSPECTOR COPY
' I