9276 APPI,ICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LD1 NG PROJECT I DENT[FICATLIEL PERMIT NUMBER
APPLICATION & PER a
ADOREss
12 L UILDING-ELECTRICAL-PLUMBING-MECHANICAL 9276
1 / Owry R'S J - PLAN CHECK VALIDATION
"" �j ''j q O V. ELECTRIC PERMIT FEE.
RA (, PHONE `/IL
I
I NAMERAc*oR OUTLETS-SWITCHES-RECEP 10.00/1.00
eS• o.• LIGHTING FIXTURES 10.00/1.00
C-o TRACTOR' PPLIANCES-RESIDENTIAL 4.00
ADDRESS
D 6_F _ 41. z� PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
aoo Ess END SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
Ilp TEMP.METER OR POLE INS. 20.00 PAID
APPLICANTS
pOGRE55 MOTORS SEE FEE$CH.
SERVICE CHANGE 20.00 JUL 121985
woo LICENSED CONTRACTORS DECLA 10 TEMP.POLE 30.00 city
�1f r p�{Ip
<u 1 hereby affirm that I am licensed under provisions of Chapte 9 CIL) f55UA P&P
,HA $w (commencing with Section 7000)of Division 3 of the Business and LH.
y BLDG. ELEC PG. MEC
F o x Professions Code,and my license is in full force and effect El 101 1:1o 0 H o' License Class Lic.Number
T r w Dam - Contractor
m e a OWNER-BUILDER DECLARATION I BUI G PERMIT
o d u INFORMATION I,
w ; a-y 1 hereby affirm that I am exempt from the Contractors License MISC.- REFER TO ORD
F w w J Law for the following reason.(Sec.7031,5,Business and Professions pERMIT ISSUANCE 10.00
VALUATION S/FT.
Code:Any city or county which requires a permit to construct,alter, '
a
s- improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO.¢ ELEC.
DLL requires the applicant for such permit to file a signed statement that TOTA
' w $ he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
H z a 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
ic H the basis for the alleged exemption.Any violation of Section 7031.5 STORIES PE CONSTR.
u ; by any applicant(.,a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7144, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.08 sQ FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are not intended oroffered f.,sale.I C however,the building GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner-
. GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
bur der wll have the harden of proving that he did not build or inh- BUILDING USE
Pro ,purpose of salcJ' INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB oma,
miowner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑tractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
ons Code:The Contractor's License Law docs not apply
r of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
r such projects with a contrctor($)licensed pursuant toSEWER-SANITARY-STORM EA.200ft/10.00loi s Lie..L'aw. TRACT NO. PARCEL NO.
exempt under Sec. ,B.&1'.C.for thisWATER HEATER W/VENT 6.00
Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
O R K E RS'COMPIiNSATION IiCI-A RATION WATER TREATING EQUIP. 5.00
u I hereby affirm that I have a certificate of consent to self-insure. - 20NING ENO.SITE NO.
or n certificate of Workers'Compensation Insurance,or a certified
copy thereof(Ser.3800,Lah.C.).
Policy No.. Company
0 ❑ Certified copy is hereby furnished. FIRE SIR INK ENERGY TZ4
H ZO ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD, v N v N
A Int uv ❑ ❑ ❑ ❑
� N CERTIFICA'1'Ii OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
UJ COMPENSATION INSURANC17 PLG.CONTR. LIC.NO. PLG.
CIL o (This section need not be completed if the permit is for one TOTAL v❑ N❑ Y❑ No
=) Z hundred dollars($100)or less I
U O 1 certify that in the performance of the work for which 11"'per- OTY. MECHANICAL PERMIT FEE .FEE SUMMARY
IL I- mit is issued, I shall not employ any person in any manner so as to
O U become subject to the Workers'Compensation Laws of California.
y
Date-Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>_ N NOTICE TO APPLICANT: If,after making this Certificate of Ex=
f.. ? empli.n,You should become subject 1.the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
5 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 1000C.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a constructinn 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 HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
+� I certify that I have read Ibis application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city and county PLUMBING
�prdinances and stale laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
' erchy authorize representatives of thiscityto enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SGH. MECHANICAL
hiibove-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
in any way acerae against sur ly in.c.nsnluence of the
grant ng of this permit' MECH.CONT. LIC.NO. MECH.
Z' TOTAL TOTAL
ore of Applicant/Contractor Date
OFFICE COPY