10911 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY.
BU LDI NG PROJECT I DENTI FICATI ON - - PERMIT NUMBER
OU11DING APPLICATION & PERMIT Iq 0 q q
ADDRESS BUILDING - ELECTRICAL-PLUMBING-MECHANICAL I I I
' OWNER PLAN CHECK VALIDATION
NAME CITY. ELECTRIC PERMIT FEE
IV �-
C. e!PB5 vNON ,5
ODNTRACroR's IUTLETS-SWITCHES-RECEP 10,00/1.00
NAME
/ LrC.No. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S - PPLIANCES-RESIDENTIAL 4.00
AODR Ess
1 - 7'z5 PQ � PHONE PANELS •10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINE -
(3 " LIC.NO, SIGNS TRANS. _ - 3.00
AARCH OR
DDRESS ENG. - SPECIAL CIRCUIT 5,00 n PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
ADDRDREss
AMOTORS SEE FEE SCH.
Ess
SERVICECHANGE 20.00 �n(1��/r/b
'0TH' O o LICENSED CONTRACTORS DECLARATION - T/T/ d
c is I hereby affirm that I am licensed under provisions of Chapter 9 E DATE
In< H (commencing with Section 7000)of Division 3 of the Business and PLG. MECH.
H y z Professions Code,and my license is in full forceand effect. i ❑ El 1:11:1z 0,� - License Class Lic.Number
9 y H CeJ Date Contractor
-
Ic m E - BUILDING PERMIT
0w OWNER-BUILDER DECLARATION' INFORMATION
E
;LL N I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION $/FT.
HU0< Lawfor the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE - 10.00
an Code:Any city or county which requires a permit to construct,after,
a p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE, LIC.N0. ELEC.
DLL requires tine applicant for such permit to file a signed statement that + TOTAL PER IT TO
whe is licensed pursuant m the provisions of the Contractor's License �A/Lsf,(/
Hzi Law(Chapter 9(commencingwitln Section 70000olDivision 3 of the Ld r
IQFfy
- a Rusineu and Professions Code)or that he is exempt therefrom:md CITY. _ PLUMBING PERMIT FEE
ce the basis or the alleged exemption.Any vlolat ion of Sect ion 7031.5 - ,ST RIES. TYPE Q6NSTR.
d ; - by any applicant lot aper;nit subjects the applicant to a civil penally ALTER-DRAIN&VENT,WATER (EA.) 5.00 '
of not more than five hundred dollars(E500J., -
- ❑ 1,as owner of the property,,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCG GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not -
intended or offered for sale(Sec. 7144, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00 '
Code: The Contractor's License Law does not apply to an owner of - - -
himPertywhOuighhlds or'weemloyethereon,
,,provand who tdoes
inch improve.'
work FIXTURES-PER TRAP 5.00 SQFLFLOORAREA' TOTALACREAGE
himself or through his own employees,provided that such improve
mems are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1INC.4OUTLETS 6.00 ,
or improvement is sold within one year of completion,the Owner. GAS EASYSTEM OVER 4 (EA.) 200
builder will have the burden of proving that he did not build or int - . - . .
- BUILDING USE
prove for purpose ofsaleJ. - INDUSTRIAL WASTE INTER3000 RES IND CON PB Dither
. .
❑ I,as owner of tine property,am exclusively contracting with ❑ ❑ Cl ❑ ❑
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 IEA.) -1.00
contracts for such projects with a contraclor(sl licensed pursilant to
the Contractor's License Law. Q 4EWER-SANITARY-STORMEA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I urn exempt under Sec. ,B.&P.Cf hir this WATER HEATER W/VENT 6.00
reason
Owner Date - WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKF.RS'C PENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to sel Ginsure, - - ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,ora certified
copy thereof(Seo'3800,Lob.C.).
Policy No. Company
Q, ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
ZZ ❑ Certified copy is filed with the city inspection division.
O Applicant _ MISC.- REFER TO ORD. Y'❑ ^N❑ Y'❑ N[3~ yPERMIT ISSUANCE 10.00
Lu - CF.RTI FICM EXEMPTION FROM WORKERS' PERMIT ZONE A.L.U.C.
W CO
� COMPEE NSATION INSURANCE' PLG.CONTR. LIC.NO. PLG. '
CL Cl( This section need not be completed if (lie permit is for one TOTAL Y❑ N❑ Y❑ N
hundred dollars(S 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'j- mit is issued,I shall not employ any person in any manner so as to
UU become subject to the Workers'Compensation Laws of California.
w ' Date Applicant BUILDING n .
a ALTER OR ADD TO MECH. 5.00
} N NOTICE TO APPLICANT: If,after making this Certificate of 1:
F2 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 l0=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the
3097 eCrloiv C ante of the work for which this permit Is issued(See. HEATING^'UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name - HEATING UNIT 100,000 B.T.U.)9.50
-Lender's Address - . ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4,00 .
information is cornet.1 agree to comply with all city,and county PLUMBING
ordinances and state lows relating to building construction, and BOILER-COMP(3 H.P.or 100,0006.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes, BOILER-COMP,IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indcmnify.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
graNing Of this permit - MECH.CONT. LIC.NO. MECH.
e. . TOTAL TOTAL -27 v
Signature of App[ a /Contractor D e
OFFICE COPY