C9123 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
OORE55 Q1
BUILDING - ELECTRICAL-PLUMBING -MECHANICA V 12
OwrvE 'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
•\ PHONE SIC
NAMER ro s UTLETS-SWITCHES-RECEP 10.00/1.00
LIC NO. LIGHTING FIXTURES JD.00/1.00
ADDRESS
CONTRACTOR PPLIANCES-RESIDENTIAL 4.00
y
In PHONE PANELS 10.00 DATE OF APPLICATION
Rcnrt ECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.N0.
OR
O
ENGINEER
uc.rvo, SIGNS TRANS. 3.00
nooeEss END • SPECIAL CIRCUIT 6.00 PERMIT VALIDATION
zlv TEMP.METER OR POLE INS. 20.00
APPLICANT'S S G
ADDRESS MOTORS SEE FEE SCH. ,
SERVICE CHANGE 20.00
oo LIC,NSED CONTRACTORS DECLARATION TEMP.POLE 30.00 /
L,u I hereby affirm that 1 am licensed under provisions ol'Chapter 9 ISSUANCE DATE
so z w (commenem ith Section 7000)of Division 3 of the Business and
w C w g w BLDG. ELECT. PLG. MECH.
F w z Professions Code,and my license is in full force and effect. ❑ ❑ ❑ ❑
z o m - License Class Lic.Number
Q z r w Date Contractor
xfrti
w a OOWNER-BUILDER DECLARATIONDECLARATIONBUILDING PERMIT
INFORMATION
AOA MISC - t REFER TO ORD
w S m- I herby aflinn that I um axemptrom the fContractor's License .
ac
LL 0 Law for the following reason.(Sec.7031.5, lu
Businessand Professions PERMIT ISSUANCE 0 VALUATION $/FT.
Code:Any city or county which requires a permit to const rue I.alter,
cera Improve,demolish,or repair any structure,prior to Its Issuance,also ELEC.CONTR. LIG NO. TE LEC, (ti
o u requires the applicant for such Per..it to file a signed statement Him TOTAL � PERMIT TO
n ea m he is licensed pursuant to the provisions of Ora Contractor's License
H. Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe ��+�/
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
R Im the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a3 _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -MATER (EA.) 5. 0 )
of not more than five hundred dollars(5500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEV ICE 4. OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sr,. 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
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SOFT.
FLOOR AREA TOTAL ACREAGE
• himself re through his own employees,fors,Provided that such improve W b ,\x
himself
inents ore not through
su provided
however,suthe buildi e. GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or int / BUILDING USE
Prove for Purpose ofsale.l' INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ os".,
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 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 o contractoos)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ l arncxempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
Eason
'X owner Dat�p-fj WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
e.+ " WORKERS'COMPBNSATION DECLARATION WATER TREATING EQUIP, 5.00 s" -
I hereby affirm that ],have a certificate of consent tassel Gin sur.,
Ur a ec'lificale of Workers Compensation In.almnce.or a certified ZONING ENG.SITE NO.
,copy thereof(Sec.3800,Cab.C.),
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z Cl Certilied'cnpy is tial with lire city inspection division.
O Applicant MISC.- REFER TO ORD. YE] NE] YE]_-NE]
M N CERTIFICATE 01'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W > COMP[!NSAT'ION INSURANCE PLG.CONTR. LIC.NO. P , ry.� Y N❑ •Y E] N�
C' O (This section need not be completed if the permit is for one TOG.AL
Z) Z It and red dollars(S 100)or less.)
U O 1 certify that in the performance of the work for which this per- CITY MECHANICAL PERMIT FEE FEE SUMMARY
LL 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 Uate Applicant E ALTER OR ADD TO MECH. 5.00 BUILDING
} W, NOTICE TO APPLICANT: If,after making this Certificate of Ex
F" ? emption,you ahoWd become subject to Ore Workers'Conmpensatioll APPLIANCE _ 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
CJ such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER10=C.F.M.) 6.00 SEISMIC FEE a�
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.). - HEATING UNIT.(TOloo,000 B.T.U.) 8.00
'•.Lender's Name
Lender's Address HEATING ON IT(OVER100,000 B.T.U.)9.50 ELECTRIC
i
1 certify that I have read this application and state that tiro above VENTILATION FAN'(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.Or100,000 B.T.U.) 6.00
hereby authorize representatives of this city R enter upon/the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL - w
aboveanenlioned properly 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 CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00 D
gr'nting ofthis permit. MECH.CONT. LIC.NO. MECH.
at r Phca1ll/C Irt ct Dae TOTAL / TOTAL
/ INSPECTOR COPY '
I