9251 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LD1 NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADD Ess AveSO ABUILDING - ELECTRICAL-PLUMBING-MECHANICAL 92 1
OWNER'S PLAN CHECK VALIDATION
NAME (/. QTY. ELECTRIC PERMIT FEE♦ G I ey Z/) PRONE!- -/ /�
NAAMERAcrORs 1 ) OUTLETS-SWITCHES-RECEP 10.00/1.00
Q vV1vp LIC.No. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S
ADDRESS oR�s
PPLIANCES-RESIDENTIAL 4.00
'Q (-VI a PHONE PANELS 10,00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CH
OPCK FEE P.c.No:
R
ENGINEER
iStl Ilel
rV
uc.No. SIGNS TRANS. 3.00 .1
ARCH.ESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
54 W9 ZIP rEMP.METER OR POLE INS. 20.00
Ar$
ADDDRESSDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
oO LICENSED CONTRACTORS DECLARATION TEMP.POLE 30,00
v u I hereby affirm teal 1 am licensed antler Provisions of Chapter 9 ISSUANCE DATE
(contmea9ng with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG, MECH?'
Fi Professions Code,and my license is in full torte and effect.
❑ ❑ ❑
,e 0 w - License Class Lic.Number -
0 m 0 Date Contractor
a a E BUIL ING PERMIT
¢ ¢ OWNER-BUILDER DECLARATION
a o i e' MISC.- REFER TO ORD INF RMATION
w g LL y I hereby affirm that I am exempt from the Contractor's License VALUATION
H u0 ¢ Law forthe following reason.(Sec,7031.5allu,CcMand Professions PERMIT ISSUANCE 10.00 5/FT.
Code:Any city or county which requires'a liermil to construct,alter, i
¢ ¢ < improve,demolish,Or repair'any structure,prior to its issuance,also ELEC.CONTR. LIC.NQ ELEC.
aG , requires the applicant For such permit to file a signal Statement Ilial TOTAL PERMIT TO
F
m w he is licensed pursuant to the provisions of the )Contractor's License
Hz Law(ChapterProfessions
Codeng )or Sectionhe is exempt
and
1
¢ Business and Professions Code)or that he isaxempl therefrom 1.5 DTV. PLUMBING PERMIT FEE
¢ r o the basis for the alleged exemption.subjects
Any applicant
of Section malty STOR P COry STR.
d 3 e0 by any applicant(Ora permit subjects the applicant to a civil penalty
of not more than five hundred dollars(SS00).1: ALTER-DRAIN& VENT-WATER (EA.) 5.00
thApp 1,as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
sole compensation,will do the work,and the structure IS not
inlanded or offered for Sale (Sec 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 -
Code:The Cnn tractor's License Law does not apply 10 an owner of
property who builds of Improves thereat,and who does Such work F IXTUR ES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself re of rote his own employees,provided that such int building
move-
ments a not intended or n ffered foremployee.pro L Imweved that r.such
he building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, - . .) 2.00 the owner- GAS EASYSTEM-OVER 4(EA
builder will have the burden of proving that he did not build or int BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ I,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 SESSORS PARCEL NO.
and Professions Code:The Conwelor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
commas for Such projects with a coetruct...IS)fiernsed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. - RACT N0. PARCEL NO.
❑ 1 ant exempt under Seo, .B.&RC.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
CC.GATE ACO.FILE NO.
WORK ERS'COMPENSA'NON DECLARATION WATER TREATING EQUIP, 5.00
1 hereby affirm that I lave 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. ('.ontpany
O ❑ Certified copy is hereby furnished, FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant V❑ IN[J Y ❑ N❑
W CERT]FICA'I'E OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU COAIPIINSATION INSURANCE PLG.CONTR. LIC.NO. PLG. V❑ N❑ v ❑ NE]
Z( This Section need not be completed if the permit is for one TOTAL
hundred dollars($100)or less.)
U O 1 certify that in the performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL P mit is issued,I Shull not employ any person m any muvner,So as to
Ow becor7ic St act In the Workers'Compensation lawsof California. BUILDING
0. Dam APPlmunt ALTER OR ADD TO MECH. 5.00
} to NOTICE TO APPLICANT': If,after making this Certificate of Ea-
H Z emporia,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 be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.NL) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p00C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
lire performance 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 HEATING UNIT(OVER 100,000 B.T.U.)Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• information is correct. 1 agree to comply with.Ii city and county PLUMBING
oofinances 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 this city to older upon the BOILER-COMP IOaRr 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection this
purposes.
(We) agree to save, indemnify and keep harrnless 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
grunting Of this permit. MECH.CONT, LIC.N0. MECH.
g aTOTAL TOTAL
S ajute of Applicant/ ontraclor mat
INSPECTOR COPY