09596 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BVI LDI NG PROJECT I DENTI FICATIAhk PERMIT NUMBER
ADuL.IN3 APPLICATION & PER 09596
m ORE
s
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S
PLAN CHECK VALIDATION
NAME
• OTY. ELECTRIC PERMIT FEE
/R
CONTRACTOR
PHONE
N°MERACTORS
UTLETS-SWITCHES-RECEP 10.00/1.00
N s S uc.No. LIGHTING FIXTURES 10.00/1,00
CONTRACTOR'S PPLIANCES-RESIDENTIAL 4.00
ss
ADDRESS
PHONE 2 PANELS ` 10.00 DATE OF APPLICATION
OR
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE
O
ENGINEER
LIC.No. SIGNS TRANS. . 3.00
ADDRESS ENG SPECIALCIRCUIT $,QO PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT NS MOTORS SEE FEE SCH. �- J
ADDRESS
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a U I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE GATE
v,Q h (Commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H H z Professions Co��11c.and qqfy��''c�ense is in full force aJ!I efeffeecct ❑ ❑ ❑
z O m - License Clussf�7�!_. s-Lic.Number.ey..;�_y_y�-�
Q z w Date Contractor
BUILDING PERMIT
¢ a ¢ OWNER-BUILDER DECLARATION
A o=° MISC.- REFER TO ORD INFORMATION
u w I hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
r .. Oa Law forthe following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requlresa permit to construct,alter,
rt ¢¢0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
- O a, requires the applicant for such permit to file a signed statement that TOTAL
ea $ he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
FiQ
La.(Chapter 9(commCuCmgwitb Section 7000).1Division3of the
Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
S= the basis for the alleged exemption'Any violation of Section 7031.5 STORIES TYPE CONSTR.
a ; by any applicant for a permit subjects the applicant loo civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sok Compensation,will do the work,and the strut lure 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 FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
• ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Omer
prove for C,p..of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of life property,ani exclusively contracting witlf ❑ ❑ ❑ ❑ ❑
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 z License Law does not apply
to an owner.f properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,B&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of C.nselr to self-insum' ZONING
or a certificate of Workers'Compensation Insgmnce,or a certified ENG.SITE NO.
COPY thereof lSec.3800.Lab.C. ��C.�`��
Policy er Company -
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified py Is fil 0 inspection division. MISC.- REFER TO ORD.
D Applicant Y❑ N❑ Y ❑ N❑
ir N CF:RT 1171CAT'I:OF I,X I:M I,noW FROM WO R K 1:RS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU >_ COMPENSATION INSURANCE PLG.CONTH. LIC.NO. PLG.
CL C3 (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ NE]
Z) Z hundred dollars IS 100)or less.)
U O I certify that in the performance.f the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any person in any manner so us to
oU become subject to the Workers'Compensation Laws of California.
UJ Dale ApplicantALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICH to APPLICANT: U',otic,making this Certiticme of Fx-
F ? 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(Tvlirbj000c. 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNITIOV C. .M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD ( UCT) \(000
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Cie,C.). HEATING UNIT(TO 100,00 .) 6.00
Lender's Name HEATING UN IT(OVE OOO B.T.U.)9.50 ELECTRIC
Lender's Address
I certify that I have read this application and stu4 that the above VENTILATION FAN (SINGLE) 4.00
• information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMPI3H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000BTU)SEE FEESCH. MECHANICAL ._.i
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 Q CONST.TAX
may in any way accrue against mid City in consequence of the
grentin of this permit. MECH.CONT. LIC.NO. MECH.
TOTAL d TOTAL
S .lucof Applin t{6wWacl Date
OFFICE COPY