9440 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION - PERMIT NUMBER
2u11DING APPLICATION & PERMIT
X � ' 53 E1�� V,) V1-14 a BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
' \ ER's
OWN
NAMPLAN CHECK VALIDATION
NAME (/� QTY. ELECTRIC PERMIT FEE
r'�A_R ( F3 Gr . P�oN ' -�_ lss
CONTRACTORS ' UTLETS-SWITCHES-RECEP 10.00/1.00 �0
LIc.NO, LIGHTING FIXTURES 10.00/1.00
ADDRESS
OR's PPLIANCES-RESIDENTIAL 4.00
CONTRACTORS
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
LIc.No, SIGNS TRANS. 3.00
ARCH.SS ENG' SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
zIPITEMP.METER OR POLE INS. 20.00
APPLICANT'S MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 p///
tact. TEMP:POLE bN 30.00 /0
FOD LICENSED CONTRACTORS DECLARATION
a v w 1 hereby affirm that I am licensed under provisions of Chapter 9
y a N (commencing with Section 7000)of Division 3 of the Business and - ' ' IS ANCE DATE
F w z Professions Cade,and my license is in full force and effect. Uwll�
E!J BLDG. ELECT. PLG. MECH.
z o u- License Class Lic.Number
o m F w Dale Cco tmefor a, ¢ OWNER-BUILDFR DECLARATION BUILDING PERMIT
°a " MISC.- REFER TO ORD INFORMATION
F
5 LL s- 1 hereby affirm that I am exempt from the Contractor's License
u o a Law for the following reason.(See.703 1.5,Business and Professions VALUATION $/FT.
Code:An cit orcounl PERMIT ISSUANCE 10.00 tC+
Any y yon.(Se . 031. ,Businocon Professions
U
iat 0iaimprove,demolish,or repair any structure,prior to its issuance.also ELEC.CONTR. LIG NO. ELEC �_
o¢ requires the applicant for such permit to file a signed statement that TOTA.L
a w m¢ he is licensed pursuant to the provisions of the Contractor's License O PERMIT TO -
Fya Law(Chapter9(commencingwithSection7000)ofDivision3ofthe ELEe�7
4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE /
in I-m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a ; � by any applicant for a permit subjects the applicant toa civil penalty gLTER-DRAIN&VENT-WATER (EA.) 5.00
of not mom than five hundred dollars($504):
❑ I,as owner of the properly,or my employees with wagesas BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their wile compensation,will do tile work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,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 F IXTUR ES-PER TRAP 5.00 so.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
reents are or intended or offered for Sale.If,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON Pe Omer
❑ I,as owner of the property,am exclusively contracting with
licensed contramors to construct the project 1Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code The Contractor's License Law docs not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contmaor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-,BAPC.for this WATER HEATER W/VENT 6.00
reason
Owne Dan WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO,
WORKF-RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm hurt I have t 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.CJ.
Policy No. Company
O ❑ Certit'ied copy is hereby famished.
Z Z ❑ Certified copy is filed with the city inspection division. FIRESPRINK ENERGY T 24
F Q Applicant MISC.- REFER TO ORD. Y❑ N❑ Y[] NE]
Cr Ln CERTWICAT Ii OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A,L.U.C.
LU > COMPf�NSATION INSURANCE PLG.CCNTR. LIC.N0. pLG.
CL
(This section need not be completed if the permit is for one TOTAL Y E] N Y ❑ NEI
Z hundred dollars($100)or less.)
V O 1 certify that in the performance or the work far which'his per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,1 shall not employ any person in any Intoner so as to
0 Cl become subject to the Workers'Compensation Laws of California.
a Date Applicunl ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE:TO APPLICANT: If,after making this CertiGca'e of Ex-
I- Z emption,you should hecome subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK
Provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.NL) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 1000CF.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,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lenders Address HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC aQ
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct,1 agree to comply with all city and county BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and stale laws relating to building construction, and
hereby enti orire representatives for ins inspection
this city to enter upon the 861LER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property forinsp of this
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 way accrue against said City in consequence of the
granting of this permit. MECH.CONT. LIG NO, MECH.
X - s TOTAL TOTAL
ignaturc of Applicant Contractor Uat
OFFICE COPY