8741 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
/ - BU I LDING PROJECT I DENT]FICATI ON - PERMITNUMBER
TA ILDING APPLICATION & PERMIT
ooREss61-2
�GZjJ�fo BUILDING -ELECTRICAL-PLUMBING-MECHANICALPLAN CHECK VALIDATION
r E OTY. ELECTRIC PERMIT FEE
1v orvE
NAME OUTLETS
UTLETS-SWITCHES•RECEP 10.00/1.00
LIC.No.. LIGHTING FIXTURES 10,00/1.00
ADDRESS DR's APPLIANCES-!RESIDENTIAL 4.00
e PHONE PANELS 10.00 DATE OF APPLICATION
on
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.OR,ENG. PERMIT VALIDATION
ADDRESS I' SPECIAL CIRCUIT 5.00
ZIP EMP.METER'
OR POLE INS, 20.00
APPLICANT's
ADDRESS MOTORS SEE FEE SCH, pA
SERVICE CHANGE' 20.00
M o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 ,1 (,! .
<v I hereby affirm that.I um licensed under provisions of Chapter 9 'V U I UA
H Z w ISSUANCE DATE
¢ e (commencing with Section 7000)of Division 3 of the Business and BLDG. ELF,rLTn P G. M H
F o mz Professions Code,and my license is in full force and effect LpBLDG �Mj
z0 0 ov 0 License Class Lic.Number
,A H j
Date Contractor
G Y f w
¢ ¢w s¢i OWNER-BUILDER DECLARATION BUILDING FERN
X u 3 6'� I hereby affirm that I am exempt from the Contractor's License
MISC.- REFER TO ORD INFORMATION
O¢ Law far the following reason:(Sec.7031.5,tlusiness and Professions VALUATION $/FT.
r - PERMIT ISSUANCE 10.00
w0 Code:Any cityorcounty whichrequiresapermittoconstruc[,alter,
ac rc ¢a improve,demolish,or repair any structure,prior to its issuance,also EIEC.CONTR. LIC.NO, ELEC.
wO u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
$x he is licensed pursuant to the provisions of the Contractor's License
Hz > Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
4 0 Business and Professions Cotte)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢ H $ the basis for the alleged'exemption.Any violation of Section 7031.5 S IE .T PE CONSTR
a3 - by any applicant for apermit subjects the applicant toacNilpenally ALTER-DRAIN IEA.) 5.00
of not more than five humdmd dollars($500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE .4.00 OCC.GROUP RIES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND.' 5.00
Code:The Contractor's License Law does not apply to ua owner of
property who builds or improves thereon,and who it,,,,such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
hi-nself or through his own employees,provided that such improve- -'
t •nit._g pot intended or offered for sale.If,however,the building GAS-EA.SYSTEM•I INC.40UTLETS 6.00 ,
h:,mpr vement is sold within one year of completion,the owner-
El El 0
' it •r will have the burden of proving that he did not build or im- GAS-EA.SYSTEM OVER 4 IEA.) 2.00 BUILDING USE
P efar purpose of sale.). RES IND CON PB Orion
• I,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 1:1XCe sed con0uctoo to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:.The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EftAimo
contracts for such projects with x contractor(s)licensed pursuant to -
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 - TRACT NO. PARCEL NO.
:❑ I am exempt under Sec..,6,&P,C.for this WATER HEATER W/VENT JUN J 6.
Owner_ Date WATER SYSTEM m55.00
ACC.DATE ACC.FILE N0.
WORK F.RS'COMPENSATION DECLARATION WATER TREATING EQUIP, City of otgn.ifu
hereby affirm that I have a certificate of consent to self-insure,
or a certificate of.Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy lhercof(Sce.3800,Lah.CJ.
Policy No. Company
0 ❑ Certified copy is hereby furnished. f
Z Z ❑ Certified copy is tiled IRE$PRINK ENERGY T-24 with the city inspection division. � .
F O Applicant MISC.- REFER TO ORO. Nv [3 N4
cN CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00
LU
A.L.U.C.
W COMPF:NSAI'ION INSURANCIi PLG.CONTR. .LIC.NO. PLO,
(This section need not be completed if the permit is for one TOTAL V N Y [] N
Z hundred dollars IS 100)or less.) 40
U O t. 1 certify that in the performance of the work for which this per- OTV MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued. I shall not employ any person in any manner so as to
0 become subject to the Workers'Compensation Laws of California.
su Date - APPlicam . ALTER OR ADD TO MECH. BUILDING
• } tai) NOTICE TO APPLICANT: If,.after making this Certificate of Ex. 5.00 -
F ? emption,you should become subject to the Workers'Compensation APPLIANCE A� 5.00 LAN CHECK
provisions of the Labor Code, you must forthwith comply with " FEE
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OV CF. ,16:D0 SEISMIC FEE
I hereby affirm that there is a Construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Cot CA HEATING UNIT(TO 10 [�.��,a
Lender's Name
Lender's Address H EATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I C '
_I certify that I have read this application and state that the above VENTILATION FAN MINGLE)- 4.00
4 anon is correct.I agree to comply with all city and county PLUMBING
s and state laws relating Io building construction, and BOILER•COMP(3 H.P.or 100,000 B.T.U.) 6.00
nr Ihorire representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH.
ubov�S J,IlinneJ property for inspection purposes, MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,yudgments, costs and expenses whichT.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.0
granting of this perm'I. - MECH.CONT. LIC.NO. MECH.
aw TOTAL TOTAL
unalure of Applicant/Contrac Date
• - OFFICE COPY -