10214 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LOI NG PROJECT IDENTIFICATION PERMIT NUMBER
DAEG, APPLICATION & PERMIT
A 10 214
OJRES5
2ZI L BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
AME CITY. ELECTRIC PERMITFEE
5 L PRONE
NAME AciORs UTLETS-SWITCHES-RECEP 10.00/1.00
` % LIC.NO. 44 LIGHTING FIXTURES 10.00/1.00191.1
ADDREjco� ACroRs PPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE 1134 PANELS 10.00 ' DATE OF APPLICATION
AOpRCHI ECi PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
sec.No. SIGNS TRANS. 3.00
AARCH,OR DDRESS ENG, SPECIALCIRCUIT 5.00 PERMIT VALIDATION
zlv TEMP.METER OR POLE INS. 20.00
APPLICANT s
ADDRESS ' MOTORS E FEE SCH n
K
SERVICE CHANGE 20.00
Woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a u. ) hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
N z w 1 bmmencing with Section 7000)of Division 3 of the Business and
a ( BLDG. ELECT. PLG. MECH.
H D z Professions Code,and my license is in full force nd effLL 1
0 o o License Class E1��r Lic.Number Cupertino 0
w H w Date_jk Contract.,
ams 4' .BUILDING'PERMIT -
z ¢ a OWNER-BUILDER DECLARATI
o a D - INFORMATION
K
; LL h 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
LL04 Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
Code:Any city orcounty which requires a permit to construct,alter,
>
z ¢ ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC,NO. ELEC.
DLL requires the applicant for such permit t°file a signed statement that TOTAL 0
w A4 he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
HiQ
Law(Chapter 9(commencing with Section 7000)of Division 3 of the ��L.
sic Businessand Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢r $ the basis for the alleged exemption.Any violation of Sect ion 7031.5 - STORIES TYPE CONSTR.
s ; by any applicant for a permit subjects the applicant ton civil penalty ALTER-DRAM IEA.) 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 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 Contractors 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 S6 FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsurenotintended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 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 INTER3000 RES IND CON pe Omer
❑ 1,as owner of the property,am exclusively contracting with . .
❑ ❑ ❑ El
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-OVER 5(EA.) 1.00
contracts I'orsuch projects with a contractonsl licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ tum 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
1 hereby affirm that I have a certificate Of consent to sell'-insure. ZONING ENG.SITE NO.
Or a cettIicaN of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.I
Policy NO. Company
O ❑ Certified copy is hereby funis eJ. FIRE SPRINK ENERGY T 24
z Z ❑ Certified copy is Bled with the city inspection division. MISC.- REFER TO ORD.
O Applicant V N V N
~ to
�
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10,00 FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y� N� V� N�
CL Z (This section need not he completed if the permit is for one TOTAL
hundred dollars 1 S 100)or less.)
U O 1 certify that in the performance of the work for which this per- CITY MECHANICAL PERMIT FEE FEE SUMMARY
LL H mLL is issued, I shall not employ any person in any manner so as to
OW become subject to the Workers'Compensation Laws of California.
a Date ApplicantBUILDING
>_ to NOTICE TO APPLICANT: If.after making this Certificate of Ex- ALTER OR ADD TO MECH. 5,00
f- 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
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10PMC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 100000F.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
Lender's Address HEATING UNIT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and state that the aboveVENTILATION 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, andBOILER-= ,H.P.Or100,000B.T.U.I'6.00
hereby authorize representatives of this city to enter upon the BOILER-COMlP Over[00,000 BTU)BEE 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
granting of this permit MECH.CONT. LIC.NO. MECH.
` _ TOTAL TOTAL
Signa[ re of ant ontractor Date
OFFICE COPY