9182 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING
ADDRESS APPLICATION & PERM
IT 9182
pooPEss '
-- BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OwN R PLAN CHECK VALIDATION
pME
QTY. ELECTRIC PERMIT FEE
vHON S
NAMERALT s UTLETS-SWITCHES-RECEP 10.00/1.00
uc.NO. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR
ADDRESS APPLIANCES-RESIDENTIAL 4.00
'PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.O.NO.
OR
ENGINEER
uc.No. SIGNS TRANS. 3.00
ADDRESS Ervc' SPECIAL CIRCUIT 5.0Q PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
ASMOTORS SEE FEE SCH.
ADDRESS
/
SERVICE CHANGE 20.00
w02 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a U I hereby affirm that I am licenserl tinder provisions of Chapter 9 ISSUANCE DATE
y2 w (cummenaing with Section 7000)of Division 3 of the Business and
Q H BLDG. ELECT. PLG. MECH.
F D e' Professions Code,and my license is in full form and effect. ❑ ❑ ❑ ❑
z O w - License Class Lic.Number
o m F Dale Contractor
Q >! 2 -+ BUILDING PERMIT
¢ ¢ ¢ OWNER-BUILDER DECLARATION
0 o uINFORMATION
X ; LL N 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
-7$/FT.
.. o¢ Law for the following reason.(Sec.7031.5.Business and Prolessions PERMIT ISSUANCE 10.00 VALUATION
2 Code:Any city or county which requires a permit to construct,alter,
¢ ¢ Q O improve,di nn fish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
E O¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
d au m w he is licensed pursuant to the provisions of the Contractor's License
F z r Law(Chapter 9(commencing with Section 7000)of Division 3 oflhe ,7
¢ Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE L 6
rc=$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a ;._ by any applicant for a Permit subjects the applicant to a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars(S500)J:
❑ I,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 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 does itol 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,provided that such improve-
mems 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, - . .) 2.00 the owner- GAS EASYSTEM-OVER 4 (EA
builder will have the burden of proving that he did not build or im- BUILDING USE
Prove for purpose of sale.). INDUSTRIAL WASTE INTER30.00 RES IND CON PB ' Omer
❑ I,ns owner of tiretireproperty,am exclusively contracting with . ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.0 /H 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 eomracm(s)licenud pursuantto
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
L
❑ l am exempt under Sec.-,B&P.C.for this WATER HEATER W/VENT 6.00
Cason
j Owner M DmY_ WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
'0 RKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate ofconsent to sel Ginsure' ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with the, city inspectinn division.
MISC.- REF ER TO ORD.
� O Applicantv❑ N❑ I v ❑ N❑
� N CI:RI'11'ICAT E OP I.X1:M PTI ON P ROM WO R K Ii RS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.L.
L � COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y❑ N❑ v ❑ N❑
Cl- Z (This section need not be completed if the permit is for one: TOTAL 2d
hundred dollars IS 100)or less.)
V O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
L 1- oil is issued,I shall not employ any person in any nha neer so as m
V W beconm subject to the Workers'Compensation Laws of Cahlorriu. BUILDING
o. Date Applicant BUILDING OR ADD TO MECH. 5.00
>_ 0 NOTICE '10 APPLICANT: If,after making this Certificate of Ex-
F 2 emption,you should becomesubject to the Workers'Compensalion 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=C.F.M.) 4.00
CONSTRUCTION LI!NDING AGENCY AIR HANDLING UNIT(OVER IO,000C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is n construction lending agency for EXHAUST-HOOD (WITH DUCT) 5.00
lite 3097.CivC.jnm of the work I'nr which this permit is isxucd(Sec MICROFILM
HEATING UNIT(TO 100,000 B.T.U.) 8,00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lenders 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 county PLUMBING If
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authori, representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly for inspection purposes.
(We) agree to save, indemnify and keep baroness 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 th is rermil MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signat eof Applicant/ ontruct r Date
INSPECTOR COPY