11070 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
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BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT
BUILDING
AOORESs BUILDING - ELECTRICAL-PLUMBING -MEC C
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O.N OTY. ELECTRIC PERMIT E C I f S
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CONTRACTORS \\ � - OUTLETS-SWITCHES-RECEP 10.00/1.00 - gpECT10N DEPARTMENj.
N E \ 1 TIf1lT uc.NO. LIGHTING FIXTURES 10.00/1.00 LD Op CUPERTINO.
CONTRACTOR'S ' % f1 \� PPLIANCES-RESIDENTIAL 4.00
A E55 3O 1 1
PEON PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMPI 20.00 PLAN CHECK FEE
OR
ENGINEER LIC.c.No. SIGNS TRANS.
5.00
ADDRESS PERMIT VALIDATION
ARCH,OR ENG. SPECIAL CIRCUIT
ZIP EMP.METER OR POLE INS. 20.00
APPLICANTS - MOTORS SEE FEE SCH.
aOORE56
SERVICE CHANGE 20.00
'09 LICENSED CONTRACTORS DECLARATION
<uh ISSUANCE GATE
u I hereby affirm that I am licensed under provisions of Chapter 9
In¢ $ (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLC. MECH.
D Professions Cod undo cense is in full f t ❑ ❑ ❑ El
z
00. Licen la Lic.Numb
9 y-a Dale Conlructo
BUILDING PERMIT
Lr Be w u OWNER-BUILDER DECLA RATIO INFORMATION
wLL 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION S/FT.
u0a Law for the following reason.(Sec.703 1.5,Busincssand Professions PERMIT ISSUANCE 10.00
L 0 Code:Anycity orcounty which requires a permit to construct,alter,
2 ca G 2O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
O 0 rcyuires the appliC H for such permit to file a signed statement that TOTAL PERMIT TO
n w m he is licensed pursuant to the provisions at the Contractor's License AA
rii Law(Chapter 9(commencingwilh Section 7000)of Division 3 ofthe (V(
a Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
F$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
w. by any applicant for a permit subjects the applicant toa Civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not mom than Ove 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 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- GAS-EA.SYSTEM-1INC.4 OUTLETS 6.00
ments are no intended or offered for sale.If,however,the building
or improvement 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 im- RES IND CON PB Other
prove for purpose ofsale.). INDUSTRIALWASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
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 for such projects with a contlectods)licensed puouanl to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ lam exempt under Sec. .B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 qCC.DATE ACC.FILE No.
WORKERS'COMPENSATION DECLARATION IWATER TREATING EQUIP, 5.00
I hereby affirm that I have a certificate ofconsent to ulf-iosam, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
Copy the C.). !x
Policy N .LF.
O ❑ fiertified copy is hereby furnished, FIRE SPRINK ENERGY T14
Z 2 Cer' Is B ' 1y inspection division.
p Applicant MISC.- REFER TO ORD. v [:] N C] v ❑ No
�! �`�"
CC > CERTIFICATE OP EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD 2oNE A.L.U.C.
W COMPENSATION INSURANCE PLG.CONTE. LIC.NO. �Yl':, PLG.
AP, G T L YE] N[D Y NE]CL0
=) Z (This section need not be Completed if the permit is for one
hundred dollars(S 100)or less) 1 ) FEE SUMMARY
L) O I certify that in the performance of the work for which this per .QTYMECHANICAL PERMIT FEE
LL 1- mit is issued,1 shall not employ any person in any manner so as to
O w became subject to lite Workers'Compemalion Laws mf California. ^
pate' Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
}
in NOTICE TO APPLICANT': If,after making this Certificate of Ex-
Z emption,you should become subject to the Workers'Compensation APPLIANCE 0 5.00 PLAN CHECK
provisjons of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1 )tOOC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.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,Cm C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I Certify that 1 have read this application and stale 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 BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
ubove-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 Of
way accrue against said City in consequence of the
rn of th ermil I ME H.CONT. LIC.NO. MECH,
1 V2� 1 l Os TOTALI p TOTAL
i n urc of Applicant/Contract r e O
OFFICE COPY v 1 I�