9101 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS 11 Sq
q �112Ir M. BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 91 0
OWNER'5 Y PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
HONE
cioR's
NA.E R
UTLETS-SWITCHES- ECEP 10.00/1.00
NAME
�\ LIC.No. LIGHTING FIXTURES a 10.00/1.00
CONTRACT PPLIANCES-RESIDENTIAL 4.00
AOOREss
( ! PHONE I PANELS 10.00 DATE OF APPLICATION
A HL CHRET PANELS (OVER 200 AMP), 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRESS ENG' SPECIAL CIRCUIT 5.00 •.t PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
APPLI MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
oo LICENSED CONI'RACTORS DECLARATION TEMP.POLE 30.00
U w I hereby all inn that I ant licensed under provisions of Chapter 9 ISSUANCE DATE
(conunm
enug with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
leD w Professions Code and ru license is in full force and effect,
Z, o w License Clasv_�=(Y Lic.Number ❑ ❑ ❑ ❑
o z R w Date 1.}tS_Contractor n,L
UI: �i'b BUILDING PERMIT
OWNER-BUILR DECDECL A I M1 - . INFORMATION
V
w3 a I- I hereby attain that 1 ant exempt front lite Contractor's License MISC.- REFER TO ORD
Iv04 Law for the following reason.(Sec.703 T.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
r - I Code:Any city orcotmty which requires permit to construct,alter, OV D O
Qo Q O Improve,demolish,Or repair any Structure,prior to its Issuance,also ELEC.CONTR. LIC.NO. ELEC.
V LL requires the applicant for such permit to fill'a signed statement that TGTAL PERMIT TO
a w m he is licensed pursuant to the provisions of the Contractor's License n l
F z i Law(Chapter 9(commencing with Section 7000)of Division 3 of the I Uva %io
¢ Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ I o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
ca
d3:! by any applicant for a permit subjects the applicant ton civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(S500)J:
❑ 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 Contractor's License Law does not apply to an owner of _ r
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 sFT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
Rivals
entsarenotintendedorofferedforsale.If.however,the building GAS-EA.SYSTEM-1 INC.40UTLETS 6.00 o.
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
provefor purpose ofsule.). A INDUSTRIAL WASTE INTER. 30.00 RES IND CON PR arbor
CII,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to emtmrmtlthe Project(Sri, 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:'1'ho 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 contracto(s)licensed Pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License law. TRACT NO. PARCEL NO.
❑ lumevemptmtder Sea ,B.&P.C.for this WATER HEATER W/VENT 6.00
reus'on
Owner „Date WATER SYSTEM 5.00 Acc.OnrE ACC.FILE No,
WORKISRS'COMPHNSA'1'ION DECLARATION - WATER TREATING EQUIP. 5.00
1 hereby Whom that I have a certificate of consent to self-insure ZONING ENG.SITE NO.
r a certificate of Workers'Compensation Insurance,or a certified
(/ copy thereof(Sec.3800.Lab.C.).
Policy N'o. Company
Q Yf ❑ 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.
0 Applicant Y❑ NE] Y E] NE]
rcc: -n CERTIFICATE OF EXIi11 P'I'ION FROMWORKERS' PERMIT ISSUANCE 10.00 -I FLOOD ZONE A.L.U.C.
Y Y
W > (704ENSATION INSURANCE PLG.CONTR. I,•,) LIC.NO. PLG. ❑ ❑ ❑ N❑
CL ('this section need oat be cam Plated i(the permit is for one P TOTAL N
0 Z hundred dollars(5100)or less,)
U O 1 certify that in the performance of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL I- Init is issued, 1 shall not employ an),person in any manner so a5 to
U W become subject to the Workcrs'Co Cit awfo;Cali(orfuu! BUILDING `--�-y
o- Dam '07�4_y\pplicant ALTER'OR ADD TO MECH. 5.00 O'-B � �lv
W NOTI li T APPhICANT`. It u c akin fills er Fate Ex-
Z emptier,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK t
provisions of the labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be damned revoked!. AIR HANDLING UNIT(TO 10,OODGF.M.) 4.00
CONS'I'RUC'I'ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby afinn that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issuW(Sec. HEATING UNIT (TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.C•).
Leader',Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender,Address s. ELECTRIC
l certify that l have read this application and state t hat the above VENTILATION FAN (SINGLE) 4.00
to comply with all Ci .
Rumination is correct. I nevey and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP13 H.P.or 100,000 B.T.U.) 6.00 I
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCM. 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 PERMIT ISSUANCE 10.00 W CONST.TAX '
may in ny way accnre against said City in consey uence of Bet
gmIT •f this peon,. MECH.CONT. LIC.NO. MECH.
/ (o- 7- S TOTAL'/ U TOTAL
rVYl1/ Sign W AppIi t/ frac Dale /
INSPECTOR COPY
I