9502 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT 9502
ADDRESS
(01_* GS
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME CITY. ELECTRIC PERMIT FEE
vHONCONTE
NAME cogs OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME
LIC.NO. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
ADDRESSPPLIANCES-RESIDENTIAL 4.00
NTRAC
PHONE PANELS 10.00 DATE OF APPLICATION
ARcwrscT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.No.
OR
ENGINEER
LIC NO. SIGNS TRANS. 3.00
ADDRESS Ervc. SPECIAL CIRCUIT 5.60 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
Avvu ESS MOTORS SEE FEE SCH. I!//`J �(f fl�-G •
ADDREss
SERVICE CHANGE 20.00
oo LICENSED CONI'RACTORS DECLARATION TEMP.POLE 30.00 6
a u U I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
yz i (commencing with Section 7000)of Division 3 of the Business and
¢ BLDG. ELECT. PLG: MECH.
F y z Professions Code,and my license is in full force and effect. ❑ ❑ ❑
z 0 License Class Lie Number
z H Dale Contractor
¢ Y E BUILDING PERMIT
¢ a w u OWNER-BUILDER DECLARATION INFORMATION
r0a MISC.= REFER TO ORD
w g: u N I hereby alfirn that I am exempt from the Conlrmlor's License VALUATION $/FT.
H u 0 J I.aw fur the following reason.(Sec 7031.5,Businessund Professmus PERMIT ISSUANCE 10.00
Code:Any city or county which requires permit to construct,alter, /6 7
rt 2 Q 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. /
G ¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
whe is licensed pursuant to the provisions of the Contractors License
Uzi Law(Chapter 9(commencing with Section 7000)of Division 3 of the
¢ Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
¢ othe basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
aim by any applicant for a permit subjects the applicant toe civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(8500).)
❑ 1,as owner of the Property,or nay 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,AR EA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE
ruent if re or into his own employees,to,
provided however,
such imprrrvr
himself
are mt intended his or employee sa provided
that s the building GAS-EA.SYSTEM-1 INC.4OUTLETS 6.00
or improvement is sold within one year of completion, . .) 2.
the owner- GAS-EASYSTEM-OVER 4 (EA.) eulLDlrvG USE
builder will have the burden of proving that be did not build or Rn- RES IND CON PB Omar
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 ❑ EJ ❑ ❑ ❑
% L as owner of thu property,he rojecti.very(Se contracting with
and sed contract.,,od to construct the pricense Sea. 7044,Business app ss LAWN SPRINKLERS-1 INC5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to anfrowner of property who builds rimprovesthereon,and who LAWN SPR INKLERS-OV ER 5(EA.) 1.00
conIlia Contractor's
suchLicense
Lwithacontramots)licensed pursuam to SEWER-SANITARY-STORM EA.200ft/10.00
Ilia Contractor's License Luw. TRACT NO. PARCEL NO.
❑ Inm exempt under See. .BAP.C.I'or this WATER HEATER W/VENT 6.00Owner
on
f.W le
reason WATER SYSTEM 5.00 ACC.DATE ACC FILE No.
RKERS'COMPFNSAT10N DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure. ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy(hereof(Sec.3800,Lab.C.L -
Policy No Company
O ❑ Cerlificd copy is lherchy furnish'cd. FIRE SPRINK ENERGY T 24
Z 2 ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant tFLOOD
NU.[] V N[]
C
CCERTIIICATEOE EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 ZONE A.L. C.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG, N Y N
CL Z 1'This sedirin need not be completed if the permit is fur one TOTAL
hundred dollars(S I OO)or less)
U O I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL µ ...it is issued,\I shall not employ any person in any manner so as to
Ow become subject to the Workers'Compensation Laws of California, BUILDING '//
C. Date Applic°nl ALTER OR ADD TO MECH. 5.00 TS� Sa
} m NOTICE TO APPLICANT': If,after making this Certificate of lis-
F ? emption,you should become subject to the Workeri 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=CF.M.) 4,00
a. CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.RM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
tire
performance of thMICROFILM
e work for which this permit is issued(Sec.7,Cie CA HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Addy H EATING UNIT(OV ER 100,000 B.T.U.)Lender's Names ELECTRIC
I certify that I have read this applical ion and state that the aboveVENTILATION FAN (SINGLE) 4.00
1h information is correct, I agree 10 aonh PIY with all city and county PLUMBING
ordinances and stale laws relating 10 building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter Gunn the
'� above-mentioned property for inspection purposes. BOILER-COMP(Over t00,000BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify 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
ranting of this permit MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
na ore o APpI cant on mctor - Date _ S
INSPECTOR COPY