9014 'APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 9014
�
ADDRESS 9 O 1 4
BUILDING—ELECTRICAL—PLUMBING—MECHANICAL J
r OWNER'S
NAME - t r PLAN CHECK VALIDATION
ELECTRIC PERMIT -dF, -f FEE' j
PHONE
NAMi I IIIA OUTLETS-SWITCHES-RECEP 10.00/1.00
► Ic. o LIGHTING FIXTURES 10.00/1.00
r-oe aS
ADORE 5
PPLIANCES-RESIDENTIAL 4.00
\ 11 PON D PANELS - 10.00 DATE OF APPLICATION
Oc iE T PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEEP.C.NO.
OR
ENGINEER
uc.No. ISIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION
Roofless - SPECIAL CIRCUIT 5.00
'
ZIP TEMP.METER OR POLE INS. 20.00
APORIESS 6
ADDRESS MOTORS SEE FEE SCH. 41,
SERVICECHANGE 20.00
, 00 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 k
a U w I hereby affirm that I am licensed under provisions of Ceapter 9 ISSUANCE DATE
,HA ¢vAi Icommencm wI Section 7000)of Division 7 of he Rusinh a BLDG. ELECT. PLG. MECH.
Hoz Professions Cod , nd I''e se is in full far f ❑ ❑ ❑
— Livens ic.Number
4 � H °w Dare ntrucmr
Qy�
a w ¢ OWNER-BUILDER DECLARATION BUILDING PERMIT,Y
x ;LL w I hereby affirm that I am exempt from the Contractor's License MISC.— REFER TO ORD iINFO RMATI,ONj`,+>'
r LL 0 4 Law for the following reason.(Sec.7031.5,Businessandl'mfessions PERMIT ISSUANCE 10.00 VALUATION $/FT.
Code:Any city orcounty which requires a permit to construct,alter, ELEC.CONTR. LIC.NO.
ac a Q Q Improve,demolish,or repair any structure,prior to Its Issuance,also TEL EC
It, D¢ requires the applicant for such permit to file a signed statement that TOTAL
n m a- he is licensed pursuant to the provisions of the Contractor's License - PERMIT TO
La Law(Chapter 9(commencing with Section7000)of Division 3 ofthe ��� �
4 o Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
r m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
ca IL by any applicant for a permit subjects Ole applicant toa civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars 18500),)::
❑ 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 st racture is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5,00
Code:The Contractors License Law does not apply to lin owner of
property wl1a 11 oil,,m'Improves helcon,and who does such work FIXTURES-PER TRAP - 5.00 SD,FT.FLDOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsare net intended oroffered for sale.If,however,the budding GAS-EA.SYSTEM-I1NC.40UTLETS 6.00
or improvement is sold within one year of completion, the owner.
builder will have file burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose of salc.l' INDUSTRIAL WASTE INTER. 30.00 - RES IND CON PB Other
LD 1,as owner of the property,am exclusively contracting with ❑ F-1 - ❑ ❑
licensed contractors to construct the project ISce. 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 a contractor(s)licensed pursuant to _
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO, PARCEL NO.
❑ lam exempt under Sec.—.B.&P.C.for this WATER HEATER W/VEN An) 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKS RS'COMPENSA I ION DECLARATION. WATER TREATING EqYJ Jqii)-.ID0
1 hereby affirm that I have a certificate ofconsent to self-insure.
or a certificate DrWorkcrs'Co Densat ion Ins m ce, a certified ZONING ENG.SITE NO.
Coo r S ,eb,RY! r ��i folic �,rJ7!—_.r { �1❑ rI Is he fu sl FIRE SPRINK ENERGY T 24
Z 2 ❑ ertified cis fl¢ wit l e it inspection division. ❑ ❑ ❑ ❑
O Applt—no MISC.- REFER TO ORD. v N v N
CC L CF:RTIPI ATEOI EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 Z FLOOD ZONE A,L.U.o.
LU .OMP SATION INSURANCE PLG.CONTR, LIC.NO. PLGCL .
Z (This seclion
are not be completed if ilia permit is for one TOTAL V N Y N
hundred dollars(8100)or less.)
U O 1 certify that in the performance of the work for which Olis per- CITY. MECHANICAL PERMIT FEESUMMARY0 L) boutecome
is issued,I shall not employ any person In any manner so as to
=FEE
Obecome subject to the Workers'Compensation Laws of California.
ED
CL Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE TO APPLICANT': If,after making this Certificate of Ex-
F 2 emption,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,OODCF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10pMCFM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending ageney,l'or EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work Icor which this permit is issued(See. MICROFILM F
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
- .Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Icertify11,31 l have read this application and state Ola,the above VENTILATION FAN ISINGLE) '4,00
information n correct.1 agree tog to b with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and stale laws relating to building construction,andon, and
herebyauthorize representatives forms inspection
this City to enter upon the BOILER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL
heave-mentioned property torinsp ofth i 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
ay in an wa ccme against Said City in consequence of the
itingo Ilii. p iL SCH.CONT. LIC.NO. MECH.
t TOTAL TOTAL
lure EILAm no
OFFICE COPY