9193 (2) .APPLICANT TO FILL IN:INFORMATION WITHIN REDLINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION ..APPLICATION & PERMIT PERMITNUMBER
�r BUILDING -oAEn n
A° ss 7 BUILDING-ELECTRICAL-PLUMBING-MECHANICAL r7 a7
• -
OWNER'S . - PLAN CHECK VALIDATION
NAME //Ar/ /.q,, QTY. ELECTRIC PERMIT FEE '
A), ,4f //L/� LIAJ6 PHONE -
crOR's - OU
NAME OUTLETS-SWITCHES;RECEP 10.00/1.00
NAME
uc.NO. LIGHTINGFIXTURES 10.00/1.00
CONTRACTOR'S - APPLIANCES'-RESIDENTIAL 4.00 "
ADDRESS " -
_ PHONE PANEL$ 10.00 DATE OF APPLICATION
ARCHITECTPLAN- PANELS (OVER 200 AMP) 20.00
ENGINEEfl CHECK FEE P.C.N0.
`
OR
- ,
' � uc.No. _ SIGNS TRANS. - 3.00 ���
ARC".OR ENG. - 5,00 PERMIT VALIDATION
ADDRESS SPECIALCIRCUIT P
nP TEMP.METER OR POLE INS. 20.00 O`
APPLICANT'S - MOTORS - SEE FEE SCH, J
ADDRESS
SERVICE CHANGE . 20.00
.w¢ 5 DECLARATION TEMP.POLE 30.00 . PAIY w° �-7
Foo LICENSED CONTRACTOR
¢ 1 hereby affum'that 1 am licensed under provisions of Chapter 9 IS ANCE DATE
yam (commencing with Section 7000)of,Division 3 of the Business and B PLG. MECH.
r °z Professions Code,and my license is in full force and effect. - ❑ ❑
z O v°'i - License Class Lic.Number
g w F ° Date Contractor
am NO PERMIT
¢ ¢m 4 OWNER-BUILDER DECLARATION. - - INFORMATION
n H 1 hereby affrtm that I em exempt from the Contractor's Licensee MISC.- - REFER TO ORD
cu u a. .Qi Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE- 10.00 VALUATION $/FT.
H - Code:Any city orcounly which requires a permit to construct,alter, -
ac a,Q 0 Improve,demolish,or repair any strUCIWe,prior to its Issuance,also ELEC.CONTR. "LIC.NO. /�/ V
ELEC.
'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
F z r Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
4 o Business and Professions Code)or that he is exempt therefrom and QTY, PLUMBING PERMIT FEE
¢ H e the basis for the alleged exemption.Any violation of5eclion 7031.5 STORIES TYPE CONSTR. _
u ;`' by any applicant for a permit subjects the applicant toacivilpenalty ,gLTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(5500).)'.
• • ❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 a OCC.GROUP' RES.UrvITS
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.SVSTEM-11NC.40UTLETS 6.00
ments are not 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
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 Other
D I,as owner of the property,am exclusively contracting with - ❑ ❑ ❑ ❑ ❑
n' 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. ILAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ l am exempt under Sec.- .B.&P.C.for this WATER HEATER W/VENT' 6.00 _
mason _ ,
Owner ,Date WATER SYSTEM 5.00 ACC.DATE ACC.'FILE NO.
WORKERS'Q MPENSATIO CLA RATIO WATER TREATING EQUIP. 5.00 '
I hereby affirm that 1 have a certificate ofconsent to self-insure,
or a certificateofWorkers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec 3800,Lab.C.L - -
Policy No. - Company
0 ❑ Certified Copy is hereby furnished., FIRE SPRINK ENERGY T-24
Z z' ❑ Certified copy is filed with the city inspection division. MISC.-c REFER TO ORD. -
0 Applicant .' " Y ❑ IN Y ❑ N[]H rnPERMIT.ISSUANCE 10,00 FLOOD ZONE A.L.u.C.,
CERTIFICATE OF EXEMPTION FROM WORKERS'' ,
LU _ COMPENSATION INSURANCE PLG.CONTR. - LIC.NO. PLG.
CL 0 (This section need not be completed if the permit is for one _ _ TOTAL Y[:] N❑ Y❑ N❑
=) z hundred dollars IS 100)or less.) - - r
0 0 1 certify that in the performance of the work for which this per- CITY. - MECHANICAL PERMIT FEE FEE SUMMARY
U_ F mit is issued,I shall not employ any poison in any manner so as to
U+ become subject to the Workers'Compensation Laws of California. !/
y' ,Date Applicant - - ALTER OR ADD TO MECH. 5.00 BUILDING 6 r
}IN 'NOTICE TO,APPLICANT: If,aftet.making.this'Certificate of Ex-
F 2 emption,you should become 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 I0=C.F.M-) 4.00
CONST RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10)=C.F.M.) 6.00 SEISMIC FEE
1"hereby affirm that (here is a construction lending agency for .EXHAUST,H60D (WITH DUCT) 5.00 '
the performance of the work for which this permit is issued(Sec..-, MICROFILM
7097,C'v.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 1100,000B.T.U.W.50 ELECTRIC
1 certify that I have read this applicationand slate that the above VENTILATION FAN (SINGLE) '4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP I3 H.P.Or 100,000 B.T.U.) 6.00
hereby authorize representatives-of this city to,enter upon the SOI LER-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 consequence of the "PERMIT ISSUANCE 10.00
• granting of this permit I ' r MECH.CONT. LIF NO.
MECH. .
Z' i TorAL TOTAL
ngnature of A ican ontractor ate
' OFFICE COPY