9234 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI NT PEN ONLY
BUILDING PROJECT IDENTIFICATION 11W PERMITNUMBER
BUILDING APPLICATION & PERMIT w
Ss ✓ BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
9 2 3 4
WNER'S PLAN CHECK VALIDATION
AVE
QTY. ELECTRIC PERMIT FEE
PHONE
HAMERAC ORs OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO. LIGHTING FIXTURES 10.00/1.00
ADDRESSTORs _ PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. ISIGNS TRANS. 3.00
ADDRESS ENG' SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT'S
ADDRESS _ MOTORS SEE FEE SCH.
SERVICE CHANGE 70:60
O
w it /��`
wo LICENSED CONTRACTORS DECLARATION TEMP.POLE 0
aU u I hereby affirm that I am licensed under provisions of Chapter 9
Z w ISSUANCE DATE
n < (commencing with Section 7000)of Division 3 of the Business and
r 0 i Professions Code,and my license is,in full force and effect. BLDG. ELECT PLG. MECH.
Z 0 w D License Class Lia Number
m�_ Date Contractor JUL 4
a >< s BUILDING PERMIT
Be ¢ � OWNER-BUILDER DECLARATION INFORMATION
X ;u I hereby affirm that I am exempt from the Contractor's License MISC.- R pt
w LL 0 el Law for the following reason.(Sec.7031.5,Business and Professions Qbk6ft I" VALUATION $/FT.
- g PERMIT ISSUANCE 19 '0
my Codc Any city or county which requires permit foe°nstnmt,alter,
¢ < FO improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. // ev
0 LLrequires the applicant for such permit to file a signed statement that TOTAL t0
X$ he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
I-ZQ Law(Chapter 9(commenciagwith Section 7000)of Division 3 oflhe f�yt✓�G-�
4 0 Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE O
IF F $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
T ; - by any applicant for a Permit subjects theapplicam to a civil penalty
of not more than five hundred dollars($500).): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ 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 FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself Or through his own employees,provided that such improve-
.cutsarenotintended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 6.00 e
or improvement is sold within one year of completion,the owner.
builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
Prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
❑ 1,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,BusinessLAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractors License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with acontractorfs)licensed pursuant 10
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/1400 TRACT NO. PARCELNO.
❑ I am exempt under Sec. ,B,&P.C.for this
reason W WATER HEATER W/VENT 5.00
Owner Ume WATER SYSTEM S,OO ACC.DATE ACC,FILE NO.
WORKERS'COMPENSATION DECLARA P:0N WATER TREATING EQUIP, 5.00
1 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 thereoffSec.3800,Lab.C.).
Policy No. Company
C ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
_Z Z ❑ Certified copy is tiled with the city inspection division'
~ Applicant MISC.- REFER TO ORD. Yo N[] YE] NE]
w
W - CI>RTIFICATEPE PERMIT ISSUANCE 10.00
EXEMPTION FROM WORKERS' FLOOD ZONE A1.U.C.
W COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
2 (This section Reed not be completed if the permit is for one TOTAL Y[] N[] Y [:] N
hundred 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 )- mit is issued,I shall not employ any person in any manner at as to
O W become subject to the Workers'Compensation Laws of California.
Q. Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
T:
} m NOTICE TO APPLICANIL after making this Certificate of Ex
H 2 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
C) such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1Q000CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.RM.) 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.L HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address A/I Oita
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
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE BCH. MECHANICAL
(We) agree t0 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 an y accrue against said City in co�Gceegra got hi ermit. MECH.CONT. LIG NO. MECH.
TOTALTOTAL
Signaturcaf AppllCanl/Contr ctor
OFFICE COPY