10185 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDING PROJECT I DENTI FICATI ON PERMIT NUMBER
6DILmNG APPLICATION & PERMIT E 3
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BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 10185
'Ow ER'9 PLAN CHECK VALIDATION
E QTY. ELECTRIC PERMIT FEE
LCs P"DNG�S -yG�+
NAME cTORs UTLETS-SWITCHES-RECEP 10.0011.00715---
LIC
0.00/1.00 lsea No, LIGHTING FIXTURES 10.0011,00
ADDRESS roll's PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECTPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEEP.C.NO.
ENGINEER
LIC.No, SIGNS TRANS. 3.00
ARC".OR ENG. PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00
ZIP EMP.METER OR POLE INS. 0
APPLICANT'S
ADDRESS MOTORS SE PF EE SCH.
SERVICE CHANGE
wnci
oo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 I��
¢u u 1 hereby affirm that I am licensed under provisions of Chapter 9 Ind ISSUANCE DATE
o
Z w (commencing with Section 7000)of Division 3 of the Business and
G rt wz Professions Code,and my license is in full force and effect BLDG. ELECT. PLG. MECH.
H
z o y License ClassLie.Nmnber El-
8 H O Dale Contractor
a r s
¢ ¢ ¢
OWNER-BUILDER RBUILUER UIiCLARAI'ION BUI DING PERMIT
¢o(L u INFORMATION
E I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
LLOj Lawforthefollowing reason. 7031.5,BusinessmdProfessions PERMIT ISSUANCE 10.00 VALUATION S/FT.
w Code.Any city or county which requires permit to construct,alter,
¢ ¢ Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
_ O u reypirt3 the applicant for such permit 10 file a signed Sl'dlCment that TOTAL PERMIT TO
w$x he is licensed pursuant to the provisions of the Contractor's License -'
Fi > Law(Chapter 9(commencing with Section 7000)of Division 3ofthe
4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
fe r the basis for the alleged exemption.Any violation of Section 7031.5 STORIE TYPE CONS R.
a; by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars($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 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- -
ments are net intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1INE.4 OUTLETS 6.00
or improvement is sold within one year of completion,the own - .el"
GAS EASYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build orl.- BUILDING USE
po a for purpose of sale.). IN DUSTRIAL WASTE INTER. 30.00 E IND CON PB Osher
I as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
it d contractors to construct the project(Sec. 7044,Business LAWN SPRINKLER S+ 1 INC 5 6.00 'ASSESSORS PARCEL NO.
a d Professions Code:The Contractor's License Law does not apply
t an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-O A.) 1.00
contracts for such projects with a contractors)licensed pursuant to SEWER-SANITARY-STORM 2 f X0.00
the Contractor's License Law. TRACT NO, PARCEL NO.
I um exem under Scc. ,B.&P.C.for this WATER HEATER WIN 6.00
as n
Own r Uare WATER SYSTEM DD ACC.DATE ACC.FILE NO.
WOR KERS'COMPENSATI DIiCLARATION WATER TREATING EQ 5.00
I hereby affirm that I have a cert ifreate of consent to sell'-insure, -
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.CJ. -
Policy No. Company -
0 O Certified copy is hereby furnished. FIRE SPRINK ENERGY T-Z4
Z Z ❑ Certified copy is filed with the city inspection division. FIRE
- REFER TOO D.
O Applicant YLJA.L.UC.
N❑
~ sea PERMIT ISSUANCE 10.00 •r .
� CERTIFICATE EXEMPTION PROM WORKERS' FLOOD
W >_ COMPEE NSATION INSURANCE PLG.CONTR, LIC.NO. PLG.
d O (This section need not he completed if the permit is for one TOTAL �� Y❑ N❑ Y❑ N❑
:DZ hand re d 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 F- mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
0 a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
? 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
f..1 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 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 performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name - HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP (Ow,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, costs and expenses which PERMIT ISSUANCE" 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
f
gran)ipg 9f this permit MECH.CONT. LIC.NO. MECH.
1 TOTAL TOTAL
Signature of Applicant Contract ate -
/ OFFICE COPY
I