9178 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
T BUI LDI NG PROJECT 1 DENTI FICATION PERMIT NUMBER
WILDING 1I_ APPLICATION & PERMIT 9178
ADDRESS ` Vr Y,
1 BUILDING—ELECTRICAL—PLUMBING—MECHANICAL
.-Nae 'S PLAN CHECK VALIDATION
NAME CITY. ELECTRIC PERMIT FEE
PHONE
CONTRACTOR'S
NAME
OUTLETS-SWITCHES-RECEP 10.00/1.00
'IP41IC V— NO, LIGHTING FIXTURES 10.00/1.00
ADDRESS TORS APPLIANCES'-RESIDENTIAL 4.00
K. PHONE —Z_A PANELS 10.00 DATE OF APPLICATION
OR
RCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
' LIC.No. SIGNS TRANS. 3,00
ADDRESS ENG' SPECIALCIRCUIT 5.00 PERMIT VALIDATION
zIP EMP.METER OR POLE INS. 20.00 \
APPLICANT MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
Foo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
<Z w I hereby affirm that I am licensed under provisions of Chapter 9 ISSUAN DATE LG
(commencing with Section 7000)of Division 3 of the Business and
rn ¢ c BLDG. ELECT. PLG. MECH.
r w" rol'cssions Code,and my license is in full to eftecl7 ❑ ❑
z i m e License CWss i/' r_Lic.Number
,o H w Date O �+`l dS Contractor /Yns. 1 —
¢ se a OWNER-BUILDER DECLARATION — ` BUILDING PERMIT '
e, o a u INFORMATION
X g; y 1 hereby affirm that I am exempt from the Contractor's License MISC.— REFER TO ORD
�.O j Law for the following reason.(Sec.7031.5,Businessi n t Professions VALUATION SIFT.
I- — g PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
rem ¢ Im rove,demolish,or repair an structure,prior to its issuance,also ELEC.OONTR. LIC.NO.
¢ 6 O P P Y ELEC.
O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
e w m he is licensed pursuant to the provisions of the Contractor's License
r z r
Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe I
¢ Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢ r $ the basis for the alleged exemption.Any violation ofSection 7031.5 STORIES TYPE CONSTR.
i3 — by any applicant for a permitsubjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5,00
.four mor.than five hundred dollar.,($500).):'
❑ 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
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 $0,FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees,Provided that such improve-
mentsarenotintendedorofferedTer,provided
that such
building IGAS-EA.SYSTEM.1INC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
ClL 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 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-OV 1.00
contracts for such projects with a conlructons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200 0 TRACT NO. PARCEL NO.
❑ [am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VE 0
reason
Owner Date WATER SYSTEM ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EO 0 .00
I hereby affirm that I have a certificate ofconsent to self-insure, — // v
or u certificate of Workers'Compensation InsumncGs or a certifieJ 20NING ENG.SITE NO.
copy therNolwco,La ny A .- s As JA (A A
Policy N rt Company 7f thed, ✓`�s�
0 ❑ Certified appy is hereby furyy'shed.
Z Z 0 Certified y is filNwQh the "city an tio�a division. FIRE SPRINK ENERGY T-24
p Applicantp,�+a�— misc.- REFER TO ORD. Y❑ N❑ Y ❑ No
~ toPERMIT ISSUANCE
� — CIiRTIIICATEO XEMPTION FROM WORKERS' FLOOD
LL > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. c1b
CL Z( This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y.❑ N❑
hundred dollars($100)or less.)
U O 1 certify that in the performance of the work for which this per- pTY. MECHANICAL PERMIT FEE FEE SUMMARY'
LL H mit is issued,I shall not employ any person in any manner so as to
U ad become subject to the Workers'Compensation Laws of California.
C. Date ApplicantBUILDING
>_ N NOTICE TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
z emption,you should became 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=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction limiting agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,CY.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)8.50
Lender's Address ELECTRIC
1 certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information n correct. I agree to comply with all city:mit county BOILER-COMP(3 H.P.Of 100,000 B.T.U.) 6.00 PLUMBING a
ordinances unit state laws relating to building construction, and
hereby entioed representatives ec this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. 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, casts and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
granting MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
�( Signature of Applicant ntracmr Uate
OFFICE COPY
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