C8419 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
1
,1:361 LDI NG PROJECT I
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DENTI FC APPLICATION & PE&T PERMIT NUMBER
DDRESS9 ' -ELECTRICAL-PLUMBING -MECHANICAL 841
9BUILDING
OwrvERPLAN CHECK VALIDATION •
NAME DTV. ELECTRIC PERMIT FEE '
PHONE
NAMERAcroRs UTLETS-SWITCHES-.RECEP 10.00/1.00
.��``,�..,,...�r��I�y Lc.NO. Je0 LIGHTING'FIXTURES 10.00/1.00
COoaEss rowR''s �a r'}���--•s (.� PPLIANCES-RESIDENTIAL 4.00 '
ON Q PANELS 10.00 DATE OF APPLICATION
ogcnrrecr PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. '3.00 -
ADDRESS ENGSPECIAL CIRCUIT 5.00 PERMIT VALIDATION
PlbrFEMP.METER OR POLE INS. 20.00
APPLICANT MOTORS SEE FEE SCH. i
SERVICE CHANGE 20.00
'09 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 / /U
FE,W I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
Q w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F m Z Professions ' and my license is in full f r rr
Z O m - License Class "! Lic.Number - Q,lo D E ❑
ONO Date��n-.i o�� Contractor _
r.
a m f BUILDTNG PERMIT
¢o n o OWNER-BUILDER DECLARATION x rN INFORMATION
F
; H I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD r
VALUATION $/FT.
rLLLL w OJ Law for the following reason.(See,7031.5.Businessand Professions PERMIT ISSUANCE 10.00
Code:Any.city or county which requires a permit to construct,alter, C( 11 �5.-•e�YklfllJ
2 ¢ Q p improve,demolish,or repair any structure,prior to its issuance,also ELEC:CONTE. LIC.NO. ELEC.
O a, requires the applicant for such permit to file a signed stalemerd that TOTAL
a w m he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
F Z r Law(Chapter 9(commencing with Section 7000)of Division 3 of fl e
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE Cd/L4a 43114-216-
O
EZ
¢ r-m the basis for the alleged exemption.Any violation ofSection 7031.5 STORIES TYPE CONSTR.
a ; _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(SS00).):
❑ 1,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 struct re is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractors License Law does not apply to lin 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"m
Prove- GAS 6.00
rents are not intended or offered for sale.If,however,the builAing
rnd
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 INTER3000 RES IND CON PB Omer
f . .
❑ I,as owner othe property.am exclusively contracting with ❑ ❑ p ❑ ❑
licensed contractors to construct the project(See 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 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 thereon,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.
❑ lam exempt under Sec.-,It&P.C,for this WATER HEATER W/VENT 6.00
reason
Owner Date - WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKS RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to sell-insure. ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy If$ec3 Lb
Policy NN. Ccump.06
O ❑
FIRE SPRINK ENERGY T-24
Z
ZL Et Ceru d o u lie wit l e ly inspection division.APPlic:ml MISC.- Y N REFER TO ORD. ❑ ❑ Y ❑ N❑
� �
�.y CF.RTIFICATB OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
1 O (This section need not he completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
::) Z hundred dollars IS 100)or less.) '
U O 1 certify that in the performance of the work for which this per- OTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued.I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
U tL Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING 1-7Q
} W NOTICE TO A1313LICANT'. If,after making this Certificate of Ex.
F Z eruption,you should become subject ho 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 10;MC.F.M.), 4.00
. CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.P.M.) 6.00 SEISMIC FEE
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.C.). f HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name •- HEATING UNIT(OVER 100,000 B.T.U.)8,50 ELECTRIC
Lender's Address
I certify that I have read On application and State that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ardinances.and state laws relating to building construction, and BOILER-OOMP(3 H.Ror100,000B.T.U.) 6.00
hereby eutf.om representatives of this City to enter upon mho BOILER-COMP IOV,100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes. '
(We) agree to ave, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino again liabilities,judgments, costs and cxpenus which PERMIT ISSUANCE 10.00 CONST.TAX
any we accrue against said City in cmmuquence of the
gran' hi it MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL 7a°Z`�
S t pp nt/Con actor Date
OFFICE COPY -