9154 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDocioo Link Oak - 9154
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'5 / PLAN CHECK VALIDATION
NnMe E; QTY. ELECTRIC-PERMIT FEE
ONRA IaNV Pal eHONEl36
NAMERAcaoRs OU CEP 10 .00
'(' - UC.ND. LIGHTING FIXTURES 10 1,00
CONTRACTORS APPLIANCES-RESIDENTIAL 4,00
ADDRESS
JeA(I
PHOrvE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO..
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH,OR E.G. PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00
ZIP rFEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORSSEE FEE SCH,
ADDRESS
SERVICE CHANGE 20.00
Cirri LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a w
0 U I hereby affirm that I am licensed under rovisions of Chapter 9
¢ Y n ISSUANCE DATE
Prssioswith Section 700e i of Division 3 of the Business and
y ¢ (commencing BLDG. ELEC PLG. MECH.
r N Professions Care,and my license is in full tome and effect. ❑ ❑ ❑
0 o m - License Class Tie.Number
o so w 1) - _ Conlmctor
a'y f BUI I G PERMIT
¢ a0 i 0 OWNER-BUILDER DECLARATION I ORMATION
X
g a vs I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
Hu0 J Law for the following mason.(Sec.703 1,5.Businessand Professions PERMIT ISSUANCE 10 VALUATION /FT.
0 Code:Any City or county which reyuiresa permit to construct,alter, -
¢ ¢ ¢ improve,demolish,of repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. EC. J
w0 u requires the applicant for such permit to file a signet)smteonent that TOTAL f PERMIT TO
es he is licensed pursuant to the provisions of the Contractor's License
Hzi Law(Chapter 9(commencing with Section 70001oftivision 3 of the
¢ Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ F $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES T CONSTR.
o ; by any applicant In,A permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(S500)J:
❑ I,as owner of the properly,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:TI®Contractors License Law does not apply to an owner of
properly who builds of improves thereon,and who does such work FIXTURES-PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
.cuts am 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, - . -OVER 4 (EA.) 2.00 the owner- GAS EASYSTEM
builder will have the burden of proving that he did not tire
or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 RES IND CON PB Omer
. .
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ '❑
licensed contractors to construct the project(Sec 7044, Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
trod 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 co tRactor(s)licensed pursuant to SEWER-SANITAR V-STORM EA.200ft/10.00
de Contractor's License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec. BAP.C.for thin
WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC,DATE ACC.FILE NO.
WORKERS'COMPP-NSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby idtirm that I have u C'crtilic:Re of consent tU 114Ginsure X ZONING ENG.SITE NO.or a certificate of Workers'Compensation Insurance,or a certified
Cup rhereo'11'e.1100,Lab.CJ.
Pot y N'o. Company
/O Certified copy is hereby furnished. FIRE SPRINK ! ENERGY T 24
Z 2 Corti -opy is,filed with the c'y inspection division.
O / Appllc ` MISC.- REFER TO ORD. Y❑ Na Y ❑ N❑
CC rn ( PERMIT ISSUANCE 10.00
LU \ fik 114 COMPF EXEM PITON PROM WOkKIiR$' FLOOD ZONE a.L.0 c.
W � COM PIiNSATION INSURANCE PLG.CONTR. LIC.NO, PLG.
CL Z ('this section need not be completed if the permit is for one TOTAL Y❑ N❑ Y [:] N[:)N
hundred dollars($100)or less.)
U O 1 certify that in the performance of rhe work for which this or, QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U Fair is issued,I shall not employ any person in any manner so as to
become subject to the Workers Compensation Laws of California.
a Datc Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} m NOTICE: 1'0 APPLICANT: If,after making this Certificate of Ex-
F 2 emption,you should become subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply will FEE
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I 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,Gv.C.). 'fk HEATING UNIT(TO 100,000 B.T.U.) 6.00
Lender's Name ;\ HEATI NG UN IT 100,000 B.T.U.)9.50
Lenders Address ELECTRIC
I certify that I have read this application and side,that the above VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or100,000B.T.U.) 6.00
hereby authorim representatives of this city to enter upon the BOILER-COMP love,ro0,00OBTU1SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgnmats, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
granting f this penniL MECH.CONT. LIC.NO. MECH,
TOTAL TOTAL
Sig tare of Applicant/Cor1fratIcir ate
INSPECTOR COPY