0925 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDING PROJECT I DENTI FICATI ON PERMIT NUMBER
aDILDINc APPLICATION & PERMIT 0925
ADDRESS ��
/")C)` / ,tee BUILDING- ELECTRICAL-PLUMBING-MECHANICAL
V • '••C PLAN CHECK VALIDATION
OWNER'S 5l^1 a t-.y(t ice: yi 1
NAME _ CITY 1 ELECTRIC PERM17r FEE
Cr PHONE rI];I
NAMER"0T01's UTLEL--SWITCHES-RECEP 5.00/1.00
sec.No. LIGHTING FIXTURES 5.00/1.00 -
CONTRACTORSPPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT 6.00 PLAN CHECK FEEP.C.NO.
aR SIGNS - .
ENGINEER 3.00
LIC.No. SIGNS TRANS.
ADDR'EOSSs ENG' SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS �" C
SERVICE CHANGE 10.00
0 O o LICENSED CONTRACTORS 6ECLARATION
F Z w 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
Professions Code,and my license is in full force and effect. rs. El 1:1 El
m D License Class Lic.Number /I'1-Q"I
Date-Contractor
BUILDING P,ER111il„:^'',
X W< OWNER-BUILDER DECLARATION •y"W,",7fi,INFORMATIONIN,n,,L!u.':-
A. N I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
p ' VALUATION
w o a Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 6.00
Code:Anycityorcounty which requires a permit to construct.alter,
Q Q 0 Improve,demolish,or repair any structure,prior ID IIS ISSDanCe,alio ELEC.CONTR. LIC.NO. ELEC.
G ac requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w $ he is licensed pursuant to the provisions of the Contractor's License
n - „t;. .I, ..,,..r• ' '-
Fi > Law(Chapter 9(commencing with Section TODD)of Division 3 of the sy
`+ ; - /� Sl
Business and Professions Code)or that he is exempt therefrom and CITY. :,y,PLUMBING PERMIT;- y.brq -FEE'
D 8 P Y -1'= r '' ✓ "Q`w'b;'0';vr + 'fir''" ' u•.i �H.'! STORIES TYPE CONSTR.
¢ r 0 the basis for the alleged exemption,An violation of Section 7031.5 .- '.+.=e '" _ .11 ._.S _
by any applicant for a permit subjects the applicant toacivilpenany ALTER-DRAIN&VENT-WATER IEA.) 4.00
of not more than five hundred dollars(S5001.):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 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. 4.00
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 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SVSTEM-11NC.40UTLET$ 4.00
mens are not intended or offered for sale.If.however,the building
0 or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.D0 BUILDING USE
builder will have the burden of proving that he did not build or im. RES IND CON PB Omer
Prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ 1,as owner of the properly,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 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 forsu ecwith acomractods)licensed pursuant to
the Contractor's License Low. SEWER-SANITARY-STORM EA.200ft/6.00 TRACT NO, PARCEL NO.
❑ lam ezempt under wner
Sec. .B.&P.C.for this WATER HEATER WfVENT 4.00
reason
Date / OWATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK RS'COMPENSATII N�CLARATION WATER TREATING EQUIP. 4.00
1 hereby a that I have a certificate of-consent to self-insure.
or a certificate of Workers'Compensation Insurance.or a certified I ZONING ENG.SITE NO.
copy thereof(See.3800,Lab.C.L
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T24
Z Z ❑ Certified copy is fled with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y ❑ N❑ Y ❑ N❑
~ vsPERMIT ISSUANCE 6.00 FLOOOZONE A.L.U.C.
UJ CERTIFICATE EXEMPTION FROM WORKERS'
W � COMPENSATION INSURANCE PLO.CONTR. LIC.NO.
PLG.
CL o (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
0 Z hundred dollars(SIOO)or less.)
U O 1 certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY-
LL F mit is issued,1 shall not employ any person in any manner so as to
U become subject to the Workers'Cam pensa tion Laws of California. - 7
O w BUILDING -6,
y Dau Applicant ALTER OR ADD TO MECH. 4.00
} N NOTICE TO APPLICANT: If,after making this rs Compensation
sa Ex
f.• Z em vision you should become e, you
the Workers'Compensation qpp LIANCE 4.00 PLAN CHECK
provisions io the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,OOD C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE j D
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued ISec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
1 certify that I have read this application and slate that the aboveVENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county BOILER•COMP 13 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to soler upon the BOILER-COMP (Over 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 end expenses which CONST.TAX
may in any way accrue against said Ci in consequence of the PERMIT ISSUANCE 3.00
granting It is permit / MECH.CONT. UC.NO. MECH. •-'. "^, e;.
{ / TOTAL
.TOTAL: : , y
Sig lure of Applicant/ ontrao Dam
OFFICE COPY