9302 1 i
APPLICANT�TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDINGADDRESS APPLICATION & PERMIT g30Z
ADDRESS �
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'$ - PLAN CHECK VALIDATION
T rvamE QTV. ELECTRIC PERMIT FEE
PHONE
CONTRACTOR
NAME
Name OUTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
CONTRACTORS - APPLIANCES-RESIDENTIAL 4.00
ADDR E55
4 5- /PHON i PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMPI 20.00 PLAN CHECK FEE lsG
OR
ENGINEER -
I.C.NO. SIGNS TRANS. 3.00
ARCHADDRESS
ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
RE
ZIP EMP. METER OR POLE INS. 20.00
ADDRESS
ASMOTORS SEE FEE SCH.
y
SERVICE CHANGE 20.00
02 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
v 1 hereby afllnn that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w¢ w (commencing with Section 7000)of Division 3 of the Business and i BLDG- ELECT. PLG. MECH.
H N z Professions Cod aryl y license is in full fore U a J effu ❑ O ❑
Z o m - Liwnsc Cblss. s3. -Lic.Number
o m r Dale Com racmr j
m a .J, BUILDING PERMIT
2 w 4 OWNER-BUILDER DECLARATION
MISC.- REFER TO ORD INFORMATION
w Sic. y 1 hereby'affirm that I am exFnlpt from the Contractor's License VALUATION $/FT.
FLLof Law for the following reason. 7031.5,Businessand Professions PERMIT ISSUANCE 10.00
;p, Code:Any city or county which npfirnupcnnil to construct,alter,
at < oImprove,demolish,or repair any ptruclure,prior to its issuance,also ELEC.
- O LL requires the applicant for such p ELEC. LIC.NO.mit to file a signed statement that TOTAL PERMIT TO
A w m he is licensed pursuant to the provisions of the Contractor's License
Law(Chapter 9(commencing with Section 7000)of Division 3 oflhe
4 m D Business and Professions Code)or that he is exempt therefrom and TY. PLUMBING PERMIT FEE
I_ a the basis for the alleged exemption.Any violation of Section 7031.5 It
STORIES TYPE CONSTR.
. ;: 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(5500).):
❑ I,as owner of the property.or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 DEC.GROUP AES.UNITS
.their sole compensation,will do the work,and life structure is not
intended or offered I'or sale (Sec. 7044, Business and ProfessionsDRAINS-FLOOR,ROOF,AREA,EA,CON D. 5.00
Code:The Contractor's License Law does nal apply to an owner of
pnOperly who builds or improves thereon,and who does such work FIXTURES-PER TRAP -5,0-0 00 SO.IT.FLOOR AREA TOTAL ACREAGE
- himself or through his own employees,provided that such int prove
morns are not intended or offered for sale.l L however,the building GAS-EA.SYSTEM-1INC.40UTLETS 6.0 all"t-
Or improvement is sold within one year of completion, the owner- GAS-EA.SVSTEM-OVER 4(EA.) 2.00 . BUILDING USE
builder will have the burden of proving that tic did not build or im- RES IND CON PB Omer
prove forpurpose ofsale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner at the property,-am exclusively contraclin,with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sea. 7044,Business LAWN SPRINKLERS-1 INC 5 V.8. 6.00 ^ ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does 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 SEWER-SANITARY STORM EA.200ft110.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam ezcmpt under Sec. ,B.&1'.C.I'Or Ibis WATER HEATER W/VENT 6.00 p/J
on
Owner Dale WATER SYSTEM 5.00
ACC.DATE ACC.FILE N0.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent tosclhl....ue' ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec 3800,Lab.C.l.�-//
Policy No. Company /-�•n
O ❑ Certifiedcopy is hereby furor cd. FIRE SPRINK )•,ENERGY T-24
zO Certified ropy is filed with the cit inspe ion division.
?�/ Apphciun / ,f MISC.- + REFER TO ORD. Y ❑ N❑ Y ❑ NE]y/` `CE RTI[irI'i I'fS%1 PT ON FROM WORKERS' PERMIT ISSUANCE 10.00 p FLOOD ZONE A.L,U.C.
LU / COMPENSATION INSURANCE PLG.CONTR. LIC.NO, PLG.
(c Q Z II'his Section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ NC]
hu nit red dollar IS 100)or less.)
U O 1 cerlify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued.I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California. BUILDING
OIL
Date Applicant ALTER OR ADD TO MECH. 5.00
>_ to NO I'ICE TO APPLICANT: If,after making this Certificate of Ex-
FZ etuption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Lubar Code, you mRsl forthwith comply with FEE
U such provisions or this permit shall be dee...ed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0MC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the perfornfance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
y
AddreHEATING UNIT(OVER 100,000 B.T.U.)Lender's Address ELECTRIC
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• inl'nnnWion is carred. I agree to comply with all city and county PLUMBINGDO
ordinances and m slate laws relating building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 a
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
- abovomenlinned 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 ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
gra ntin,of this per til, ECH.CONT. LIC.NO. MECH. _
TOTAL TOTAL
g ata eofA phi n o raztor f
INSPECTOR COPY