09693 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON PERMIT NUMBER
OUILDING APPLICATION & PERMIT �^v n 3
n
ADDRESS
2G ? BUILDING - ELECTRICAL-PLUMBING-MECHANICAL o 9 b
OWNER'S / PLAN CHECK VALIDATION
NAME !` QTV. ELECTRIC PERMIT FEE
•� IZa O?T 'S P.ONE
CONTRACTOR S
NAMOUTLETS-SWITCHES-RECEP 10.00/1.00
E /
- Lie NO G(1 LIGHTING FIXTURES 10.00/1.00
CONTRACTORS _ PPLIANCES-RESIDENTIAL 4.00
ADD/Ess Z,
POE7a
ir 10.00U,(i l2 PANELS DATE OF APPLICATION
ARDRrtECTPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.Na. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP EMP. METER OR POLE INS. 20.00
ADDRESS MOTORS - SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 (� p/
w o it o LICENSED CON"TRACTORS DECLARATION TEMP.POLE 30.00 ///(0 O
¢ v I hereby'of firm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
I < n (CUmmPnCing with Section 7000)Of DIVISIDn 3 of the Business and BLDG" ELECT. PLG. MECH.
F, KI
m z Professions Code,and my license is a full force and ifect ❑ ❑ ❑
z o w- Llcatsc Class"Lic.Nwnber V
F D Date ll V Contractor
a , 2 BUILDING PERMIT
¢ ¢ w OWNER-BUILDER DECLARATION
w 3 LL y I hereby affirm that I am exenmt from the Contractor's License
MISC.- REFER TO ORD INFORMATION
ac Law Law for the following reason. 7031.5.Businessand Professions PERMIT ISSUANCE 10.00 VALUATION
� - Code:Any city or county which requiresa permit loconstrucLaliCq
or < 0- improve,demolish{or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NQ ELEC.
Ew 0 a, requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
d w m he is licensed pursuant to the provisions of lire Contractor's License
F z ¢
-Law(Chanter 9(commencing with Section 7000)of Division 3 ofthe M�
i i O Business and Professions Code)or that Ile is exempt therefrom andQTV. PLUMBING PERMIT FEE
¢ r o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
n ; m by any applicant for a'permit subjects the applicant to a civil penalty gLTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(5500).):
O 1,as owner of the property,or my 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,AREA,COND. 5.00
Code:The,Cmucactor's License Law docs not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself re of u ci his own tered ors,provided that such improve
atom la are thmiagh dal or niferuA for salc.ILhowevegflue building GAS-EA.SYSTEM-1INC.40UTLETS 6.00
or improvement is sold within one year of completion, the owner GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving iia(he did not build or inh RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIA L WASTE INTER. 30.00
0 1,as..net of the property',ons exclusively contracting with ❑ ❑ ❑ ❑ ❑
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 forsuch projects with a contractors)licensed pursuant to
the Contractors License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ [am exempt under Sec.-,B&P,C"for this WATER HEATER W/VENT 6.00
reason
Owner Uate WATER SYSTEM 5.00
ACC.DATE ACC FILE N0,
WORKERS'COM PENSA'I'ION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby aRinn that 1 have a certificate of consent to self-insure, zONING
or a certificate of Workers Compensation Insurance,or a certified ENG.SITE NO.
.copy thereof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Cerlouc]copy is hereby furnished. FIRE SPRINK ENERGY T"24
z.Z (1,Applicant
Tied cop 's fled wition division. MISC.- REFER TO ORD.
O 41V❑ N❑ V ❑ N❑
CC w CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOO ZOrvE A.L.0 J.C.
Lu > COMPl!NSATION INSURANCE, PLG.CONTR. LIC.NO. PLG.
d Y❑ N❑ V ❑ N❑
0 (Phis section need not be completed if the permit is for one TOTAL
Z) Z hundred dollars IS 100)or less)
U O 1 certify that in the on ornmirce of the work for which this per OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F alit is issued,I shall not employ any person in any manner so as to
U become subject to the Worker,'Coepers"at ion Laws of California.
n Dat° Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} rn NOTICE TO APPLICANT: 0',alter making this Certificate of Ex-
? omption,you should become 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 he deemed revoked. AIR HANDLING UNIT(TO 10WOCF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IQOWC.F.M.) 6.00 - SEISMIC FEE
I hereby affirm that (here is a construction lending agency for EXHAUStJHOOD(WITH DUCT) 5.00
tire 3097rc MICROFILM
once of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00
,Civ
Lender's Name
Lender's Acidic HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
ss
keertil'y that l have read this application and smile that lire above VENTILATION FAN (SINGLE) 4.00
information is correct, I agree to comply with all city and county PLUMBING
ordinani es and slate laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00
hereby authorize representatives of (his city to enter upon (lie BOILER-COMP Cos,100,000 BTU)SEE FEE SCH. 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,judgments, costs and expenses which 10.00 CJ - CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE
granting of
thhLQ NO. MECH
. . TOTAL
`
TOTAL
Signature o(Applicant/Corirumor Het
j
INSPECTOR COPY