18871 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT I,
AD RE a , I U 8 I 1
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 18871
OWNERS PLAN CHECK VALIDATION
NA l �J OTY. ELECTRIC PERMIT FEE
PNO
�• egMERA 'oRs UTLETS-SWITCHES-RECEP 10.00/1.00
LIc.N LIGHTING FIXTURES 10.00/1.00
c7oR's
nooREss APPLIANCES-RESIDENTIAL 4.00 3 ZQ
PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS(OVER 200 AMP) 20.00 PLAN CHECK FEEP.C.NO.
O
ENGINEER
LOC.No, ISIGNS TRANS. 3.00
AENG. PEI�TyB{,Lf�ATIDN
ADDRESS SPECIALCIRCUIT 5.00
AZIP EMP.METER OR POLE INS. 20.00
DRESS MOTORS SEE FEE SCH. I'��'�R i 1 (Cyd
ADDRESS
SERVICE CHANGE 20.00
o¢i ►I
r o D LICENSED CONTRACTORS DECLARATION eJ O>t�iQR nn
<u u 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
G m (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT, PLG. MECH.
F O z Professions CoJe,antl,�ny license is in full G6 J feet./ ❑ O ❑
Z D B License Clan• ._7-J� Lie Number-
0 m f w Dale_ Con Uaclor
a x f d BUILDING PERMIT
a ¢w u OWNER-BUILDER DECLARATIONINFORMATION
X A I- 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
b VALUATION SIFT.
u o Law for the following reason.(Sec.7031.5,Businessland Professions
_N g PERMIT ISSUANCE 117.00
f W9f Code:AnymolishOF cornty pair any structure P riorttoconsuanL,also
¢¢ 0 O improve,demolish,or repair any structure.prior In its issuance,also ELEC.CONTR.
LIC.NO. ELEC.
i DLL requires the applicant for such permit to file a signed statement(hat TOTAL PERMIT TO
F
S w he is licensed Pursuant to the provisions of the Contractor's License � '�J
F > Law(Chapter 9(commencing will,Section 7000)o[Division 3 ofncc
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
i O RIES TYPE CONSTR.
¢H $ the basis for the alleged exemption.subjects
Any spoken of Section malty
by any applicant fora permit subjects llcanuoacivil penally ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(S5000.):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole corn pi nowt Ion.will Jo the work,and the structure is not
intended or offered for sate(Sec. 7044, Business and ProfessionsDR AINS•FLOOR,ROOF,AR EA,CON D. 5.00
Costs The Contractor's License Law donm
docs Out apply ID ,owner of
properly who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 90,FT.FLOOR AREA TOTAL ACREAGE
J •
himselforof Intended
ownemred for sale.
cd however,tile
impmvc GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
mems are not Intended or offered tar sale.IL howevc n the building
orimprovemenl is sold within one year of cmmpletirn,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
ba
ildet will have Ilse burden of proving that Inc dill nor built) ,,int- RES IND CON PB Other
prove for purpose of sale.). INDUSTRIALWASTE INTER. 30.00 1:1 ❑ E] 0 El
❑ 1,as owner of thm
e property,am exclusively nUacling 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 IEA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to
Ilse Contractor's License Law. SEWER-SANITARY-STORM EA.2001t/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. .P.&P.C.for this WATER HEATER W/VENT .6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of conseal IR sc If insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a ec,lified
copy Iherenf(Sec.3800,Lab.CA
Policy No. Company
0 ❑ Certified Copy is hereby furnished. FIRE SPRINK ENERGY T-74
Z Z1(Certified copy is filed wills rhe city inspection division. MISC.- REFER TO ORD.
O AFpf¢ant V N V 0 N
T CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 110.90 FLOOD ZONE A.L-O.C.
CL (3W 7 COMPENSATION INSURANCE. PLG.CONTR. LIC.NO. PLG. I I Y� NE] Y EJ PIC]CL 2
(this section need not be completed if the Penni( is for one TOTAL `I
hundred dollars(5100)or less.)
U O 1 certify that in the performance of the work for which"his Per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mil is issued.I shall not employ any person in any Insurer so as to
U become subject to the Workers'Compensation Laws of California.
i Dare Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} m NOTICE.TO APPLICANT: If,after making Ibis Certificate of fix
emp(ion,you should become subject to Ilse Workers'Compensatimn APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you noxa f..thwilh comply will, FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 4.00
CONSTRUCTION LENDING.AGENCY AIR HANDLING UNIT(OVER 10p00C.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that (here is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the perlormance of the work for which this permit is issued ISec. MICROFILM
3097,Cie.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Add, HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
ess
I certify• (het I have read this application and stare that rhe above VENTILATION FAN (SINGLE) 4.00 information is correct. I agree to comply with all city and county PLUMBING I v lL W
ordinances and state laws relating to building constructioBOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00
n. and
hereby authorize representatives of this city to enter upon (he BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above mentioned properly for inspection purposes.
(We) agree to save, Indemnify and keep harmless rhe City of MISC.• REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
ay any ay rue against mid City in consequence of the PERMIT ISSUANCE 10.00
ry go Ik�i9 per Ila;�l MECH.CONT. LIQ NO. MECH. t 1,
/ . TOTAL TOTAL `kms OrD
Signalure of pplicanl/Conlraclor Ualc
OFFICE COPY