9224 (2) APPLICANT TO FILL IN INFORMATION WITHIN,RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
,ADDRESS 9 2 2 4
( l 5 BUILDING-'ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S
NAME AN CHECK VALIDATION
OTV ELECTRIC PERMIT FEE
PHONE
NAMERAcroRs OUTLETS-SWITCHES-RECEP 10.00/1.00
❑c.No. LIGHTING FIXTURES 10.00/1.00
nooeess TORS APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
OPRCNITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO;
ENGINEER
11C.No. SIGNS TRANS. 3.00
ADDDDRESS ENG' _ SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
APPLICANT'S
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 mm Q
o o' LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
¢
o r aU� u 1 hereby affirm that I am licensed ander provisions of Chapter 9
r ¢ (commencing with Section 7000)of Division 3 othe Business and .. `I
SSG NCE A
Professions Code,and my license is in full force and effect. SLOG. ELE T. PLT. MECH.
i
'
License Class Lia.Number n ❑
¢ x� J Date Contractor f�' rEr�Td\1A, Vl/f�l �glsy�
¢ ¢ w ¢ OWNER-BUILDER DECLARATION [ BUILDING PERMIT
°' U 'MISC.- - REFER TO ORD INFORMATION
X ; y I hereby affirm that I am exempt from the Contractor's License
u O ¢ Law for the following reason.(Sec.7031.5,Business and Professions VALUATION $/FT.
- PERMIT ISSUANCE 10.00
m�" Code:Any city or wr rep which squirese permit to construct,alter, �n
S, ¢ ¢Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR.- LIC.NO. V
ELEC.
- c ¢ requires the applicant for such permit to file a signed statement ehut TOTAL
n w m he is licensed pursuant to the provisions of the )ofDivisoom License PERMIT TO
H z Q Law(Chapterand
Professions
Cod )or Section is exempt
the of o of(and
M4 D Business and Professions Code)or that he is exempt ectiono0 and QTY. PLUMBING PERMIT FEE S TY CONSTR.
¢ I- $ the basis for the alleged exemption.Any violation of Section malty STORIES TYPE CONSTR.
a 3 � by any applicant fora hundred
dollars $500).he licam toacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(my em:
❑ I,as owner at the properly,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 improves thereon,and wlta does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through hisis own employeesprovided that such improve-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I-INC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 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 INTER. 30.00 RES IND CON PB Omer
❑ 1,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 contractor(s)licensed pursuant to
the Contractor's License Law., SEWER-SAN ITARV-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempla der Sea ,B.&P.C.for this
reason WATER HEATER W/VENT 6.00
Owner Dare - WATER SYSTEM- 5.00
ACC.DATE ALC.FILE N0.
" WORKERS'COMPENSATION DYCLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified " ZONING ENG.SITE NO!
copy thereof(Sec.3800,Lab.C.). -
Policy No. Company
❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY iZ4
Z Z ❑ Certified copy is filed with the,city inspection division.
H O Applicant MISC.- REFER TO ORD. y❑ N❑ Y ❑ N❑
it W CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.O.C.
LU COMPENSATION INSURANCE PLG.CONTR, LIC.NO. PLG.
L1 O _(This section neAnot be completed r if the permit is for one TOTAL V❑ N❑ V [:] N❑
Z hundred dollars($IGA or less.)
U O 1 certify that in the performance of the work for which this per- OTV MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I'shall not employ any person in any manner so as to
O Wbecome subject to the Workers'Compensation Laws of California.
Q. 'Date BUILDING
Applicant 'ALTER OR ADD TO MECH. 500
} to NOTICE TO APPLICANT: If,after'making this Certificate of Fx- .
Z emption,you should become subject to the Workers'Compensation APPLIANCE 500 PLAN CHECK
provisions of the Labor Code, you must forthwith .
comply with(� FEE 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 10=C-EM.) 6.00 SEISMIC FEE a�
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.CJ. - HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name -
Lender's Address H EATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I 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 gOILEfl-COMP(3 H.P.Or 100,000 B.T.LI.I' 6.00 PLUMBING
m
ordinances and slate laws relating building construction, and
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOI CER-COMP lover 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,j!uydg�}ments, costs and expenses which' PERMIT ISSUANCE 10.00 CONST.TAX '
may in any 4acego' st aid City inconsequence of thegrand of i ,/C/Y//^/m CONT. LIQ NO. TOTALSsgnatu f tr ' r ate TOTAL /Q S
OFFICE COPY - ( -