11074 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY
BUILDING PROJECT I DENT[FICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESSI • , 1 LanS PI`ENe 1107 4 -
u1 BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
O ER'$ PLAN CHECK VALIDATION
" E� __\_ �,\\,� 1n ^�..-�-pij11 QTY. ELECTRIC PERMIT. FEE
ACTORS TTFj PHONE ChJI ULTf
CONTRACToas UTLETS-SWITCHES-RECEP 10.00/1.00
�E�\1 LII-.NO. LIGHTING FIXTURES 10.00/1.00
coNTRAcaons
APPLIANCES-RESIDENTIAL 4.00
RE$$
PHONE • PANELS - 10.00 DATE OF APPLICATION
AR TCT - PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.No. - SIGNS TRANS. 3.00
ARCH.ORENG. , - SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 20.00 /)
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
0 0 O LICENSED CONTRACTORS DECLARATION
a.u I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
n < n (commencing will,Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H as z Professions Cod ns'I se is in full Co ❑ ❑ ❑ r�,l
Z, o m License ass Lie.Numpa� ly2il
Q m w Date Contract.
a m f BUILDING PERMIT
Ix Ic w ¢ OWNER-BUILDER DECLARATION INFORMATION
0 MISC. REFER TO ORD
X 3 LL N I hereby affirm Ihui I am exempt from the Contractor's License VALUATION VFT.
H .. N j Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alteq
a Q 2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO.
ELEC.
O LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
a w m he is licensed pursuant to the provisions of the Contractor's License
in In.(Chapter 9(commencing with Section 7000)of ivision 3 ofthe E
Business and Professions Coded or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
mthe basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
ate _ by any applicantfora permit subjects the applicant toacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500).)'
❑ 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 not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.IT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 (EA.) 200 BUILDING USE
builder will have the burden of proving that h . . .
e did not build or int- RES IND CON PB Omer
prove for purpose of sale.). I INDUSTRIAL WASTE INTER. 30.00 11 1:1 ❑ 11 ❑
❑ 1,as owner of the properly,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.8. 6.00 ASSESSORS PARCEL NO.
and Professions Code The Contractor's License Law docs not apply
to an owner of property who builds or improves fiction,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.tin this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKFRS'COMPFNSATION DECLARATION IWATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure, ZONING - ENG,SITE NO.
or a certificate nC Workers'Compensation his nee,or a certified
copy Cher
policy N�� -
O tr'dcopy"Inco,`byfurnishcd. FIRESPRINK ENERGYT-24
Z 2 Cc f, {{��''yy��s,, fi`pp�� 'ty inspection.division. MISC.- REFER TO ORD. y N y N
0 Apphcan�ilNL � T ❑ ❑ ❑ ❑
CC CERT IFICATE Off\\EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLDDOZONE A.L.0 C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. _ y❑ N❑ y ❑ N❑
CL 0 (This section need not be completed if the permit is for one T
::) Z hundred d.11...($100)or less.)
in-
L) O 1 certify that in the performance LIC tire work for which this ver- QTY. MECHANICAL PERMIT .. -FEE FEE SUMMARY
1L F mit is issued,1 shall not employ any person in any manner so as to J
O W become subject to the Workers'Compensation Laws of California. BUILDING
Date Applicant ALTER OR ADD TO MECH. 5.00
} tail NOTICE TO APPLICANT: If,after making this Certificate of Ex-
Z emption,you should become subject to the Workers'Compensation rAPPLIANCE PI 01110 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
C..) such provisions of this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10)000 .M,) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F,M.) 6.00 SEISMIC FEE
I hereby affirm that there is e(-onstruction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lenders Name HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
1 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
.�I ordinances and state laws relating to building construction, and BOILER-CONlP 13 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,o000TU)SEE FEE SCH, MECHANICAL Vu
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 ISSUANC 10.00 CONST.TAX.
may in any way accrue against said City in consequence of the
It r n' pCthlSpermlL M CH�CONT. LIC.NO.
TOTAL /� TOTAL
5 a ure of Applicant/Contractor ¢ A (f1 „1 w
OFFICE COP