8194 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 8� "
ADDRESS
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
59?1 PLAN CHECK VALIDATION
NAME
PITY.ONE
ELECTRIC PERMIT " FEE
eI^Pp ONE
NArne FACTORS OUTLETS-SWITCHES-RECEP
Lac.NO. LIGHTING FIXTURES /10 .00 S
noo EsC&S APPLIANCES-RESIDENTIAL 4.00
_ PHONE All! PANELS 10.00 DATE OF APPLICATION
.Lm,.ree PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
` noo iOR ENG. SPECIAL CIRCUIT 5.00 ,� PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
APPLICANT s
ADDRESSMOTORS SEE FEE SCH.
OFE55 ������
SERVICE CHANGE 20.00
- w w a\ LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 #
a O'uu I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
(comnnemmng with Section 7000)of Division 3 of the Business and BLDG. ELEC PLG. MECH.
H N�i Professions Code,and my license is in full force and efl ea. El ❑ ❑
2 D H- License Class Lic.Number
o z r Dale Contrattor
a s, - BUILDING PERMIT
¢ ¢ w a OWNER-BUILDER DECLARA'r10N
A O a D INFORMATION
X g LL H I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
LL•o a Law for the following reason.(Sec.7031.5,Businessand Professions VALUATION SIFT.
� - � .'Code:Any city or county which requiresapennit to conslnml,alteq PERMIT ISSUANCE' X10.0
¢o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. /
vu DLL requires the applicant for such permit to file a signed statement that TOTAL
u w m he is licensed pursuant to the provisions of the Contractors License' PERMIT TO
Hzi Law.(Chapter 9(commencing with Section 7000)of Division 3 ofthc
Z a o Business and Processions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
¢ H m the basis for the alleged exemption.Any violation of Section 70315 STORIES TYPE CONSTR.
ta
by any applicant for a permit subjects the applicant toa civil penally gLTER-DRAIN&VENT-WATER IEA.) 5.00
of not more than five hundred dollars($5000.):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their Sale compensation,will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CON D. 5.00
Code:'I'Im Contractors License Law docs not apply to an owner of
properly who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 EO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees.provided that such improve .
mems are not intended or offered for sale.IL however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or int, GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 R IND CON PB Omer
❑ I,as owner of the property,am exclusively contracting with El 0
licensed contractors to construct lire project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 'ASSESSORS PARCEL NO.
and Professions Code:The Contraclor'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 contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200tt/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ I ina exempt under See.-,KGI'.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK FRS'COMPENSA'f ION DECLARA'I ION WATER TREATING'EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers Compensation Insurance.or a Certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.CJ.
P.Ilcy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified s f d with II clay in Pe ;ion division. ❑ ❑ O ❑
p ApPlir, /nt 4 s�� - MISC.- REFER TO ORD. v N v N
m C RTI Ir I CATE OI°EX EM PT'I ON PROM WOR K Ii RS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.O'C.
L � COMPIiNSAT10N INSURANCE PLG.CONTE. LIC.NO. PLG, YE] N� Y � N�
C o (This section need not he completed if the Penni( is for one TOTAL
Z� Z hundred dollun(SI00)or lcss.l
U O 1 certify that in the performance of the work for which this per. CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NONCE TO APPLICANT: If,after making this CcrUficam of Fx-
F Z_ emption,you should beconne subject to 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)000QF.IVL) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction tending 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
Lnder's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I cc,t,l,Out l have read this application and state that the above VENTILATION PAN (SINGLE) 4.00
• information 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
abov aentioned property for inspection puruaws.
(We) agree to save, indenmify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
gmntin ft '.v'pennlr MECH.CONT. LIC.NO. MECH.
�7(\ _ TOTAL TOTAL
'\ ' nalur per MECH.on radar Date
INSPECTOR COPY