10957 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
XADDRESS BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 10957
OWNER'S 1 N WO PLAN CHECK VALIDATION
• NAME OTY. ELECTRIC PERMIT FEE
PHONE
CONTRACTORS OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME
uC.No. LIGHTING FIXTURES 10.00/1.00
AODURfss TOR ( { b(xI,Q PPLIANCES-RESIDENTIAL 4.00
9b9 e.i'II 40-
pHO 1111111PANELS 10.00 DATE OF APPLICATION
ARCHITEC PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH.OR ENG' SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 20.00
AppPPLICA
RESST'S MOTORS SEE FEE SCH. C)
A
SERVICE CHANGE 20.00f/I
w¢ z pA E
F D o
LICENSED CONTRACTORS UF.CLA RA'T'ION
¢ v 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE/
w¢ w (commencing with Section 7000)of Division 3 of the Business and tELE,CT. P G MEC-.
H z Professions Codc,Aly license ix in full force a d e I'e L ���''11C�f}'`�-'I„I
El
z O License Class Lic.Number f=1� u
9 t O ate Cnntracmr.
_ o O _�O -B�DF-R DECI:RATION � T'x 3 w yI hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORDUO¢ Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00ATSIFT.
Code:Any city or county which requiresa permit to construct,alter, Q "-D
Z m s- 4 0 or to its issuance,also ELEC.CONTE. LIC.NO. ELEC. /
¢ a Q O improve,demolish, r repair any structure,pri ( /
O¢ requires the applicant for such Pen»i(to file a signed statement that TOTAL PERMIT T
a w m u he is licensed pursuant to the provisions of the Contractor's License
F sea Law(Chapter 9(commencing with Section 7000)of Division'ofthe
4 O Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ $ the basis for the alleged exemption.Any violation cul Section 7031.5 STO IE E CONSTR.
A. 3 of anyoot applicanore nt
fee permit
end eddollars(the applicant tea civil penally gLTER-DRAIN&VENT-WATER (EA.) 5.00
❑ 1,as owner of the property,or my employees with wages as BACK F LOW 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,AR EA,CON D. 5.00
Code:The Contractor's License Law does not apply to an owner of
properly Who builds or Improves thereon,and Who d0cS Such work FIXTURES-PER TRAP S.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve GAS-EA.SVSTEM-11NC.4 OUTLETS 6.00
mems are nor intended or offered for sale.I l however,the building
or improvenuent 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 am. RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIALWASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑
❑ I,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec 7144,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Profession'Code:*run Contractor's License Law docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.1 1.00
contracts for such projects with a contrxclorfs)licensed pursuant to SEWER-SANITARY-STORMEA.200tt/10.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
0 I am exumnt under Sec. ,B.&P.C.Ikrr this WATER HEATER W/VENT 6.00
reason
Owner Dale WATER SYSTEM 5.00 Ace.onrE ACG FILE NO.
WORKERS'COMPENSAT1ON DECLARATION jPLG.10NTR.
TER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to sell'-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurapce.or a cerffied
copy thercol(Sec.3800,Lab.CJ.l'_,. --'}q-
Po0 N r Company_ _ _ -
Q ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z Certified cop��s wI the• city inspection division. MAN
REFER TO ORD.
Ap Ii Cant Y`r -'EPS/ Y❑ N❑ Y ❑ N❑
- (`1N 10.00 FLooO zoNE A.L.u.c.
CC - CBRT'IIICATE OF EXEMPTIO PROM WORKERS'
w > COMPENSATION INSURANCE PLG. Y❑ N❑ Y ❑ N❑
d 0 11'his suction need not be completed if the permit is for oneTOTAL
Z) 2 hundred dollars IS 100)or less.l
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEEUL FEE SUMMARY
I- mit is issued,I shall not employ any person in any manner so as to
OW become subject to the Worked'Compensation laws of California. Q BUILDING e�Q S�
Dale Applicant ALTER OR ADD TO MECH. 5.00
} y NOTICE TO APPLICANT: II,after making this Certificate of Ex-
H 2 eruption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Codc, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE O-
I herebyaffirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work I'or which this permit is issued(Sec. HEATING UNIT (TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Cr,C.).
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
1 certify that 1 have read This application and slate(hat the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county BOILER-COMP 13 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
. � ordinances and state laws relating to building construction, and
hereby aulllorim representatives of this city to enter upon lire 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 and expenses which CONST.TAX
may in any way accrue against said City in col sequence of the PERMIT ISSUANCE 10.00
gran(ingo t is emit MECH.CONT. LIC.NO. MECH.
,y �� &� TOTAL TOTAL
Signature pplicant/Genu r late
OFFICE COPY