8174 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
)' NG o ovAPPLICATION & PERMIT
ADUREa
2/ �� BUILDING-ELECTRICAL-PLUMBING-MECHANICAL n 4
NANERa y�p.2 {{'' PLAN CHECK VALIDATION
a QTY. ELECTRIC PERMIT FEE
PHONE10 Z ^Z
NAMERAcroRs UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.No. LIGHTING FIXTURES 10.00/1.00
ADDRESS TOn'S PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
OR
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEEP.C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT'6
ADDRESS MOTORS SEE FEE SCH. 9 i
SERVICE CHANGE 20.00 3 /��� r
F
00 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 /
<
UI hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
a n (commencing with Section 7000)of Division 3 of the Business and BLDG. FFyy,,EE�CTT PLG. MECH.
F D i Professions Code,and my license is in full force and effect. ❑ D❑ ❑
O Z H D License Class Lic.Number C�/ - S.
FNH J Date Contractor
IT
cc OWNER-BUILDER DECLARATION M% FbRMdYtPdIl
x ; H I hereby affirm that 1 am exempt from the Contractor's License IMISC.- REFER TO ORD
oa Law for the following reason.(Sec.7031,5.Business and Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
Code:Anycityorcounty which requiresa permit to construct,alter, City Of CupOrt no
Q Ca p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO, ELEC,
O a: requires the applicant for such permit to file a signed statement that TOTAL PERMIT T
X
$m he is licensed pursuant to the provisions of the Contractor's License NiW
Fi >
Law(Chapter 9(commencing with Section 70000.1Division 3 ofthe
4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE h e d
Ie H r� the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
o; by any applicant fora permit subjects theapplicant toacivil penally ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(5500).)'
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 ocG.GROUP RES.UNITS
their Sole compensation,will do the work,and the structure isnot
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
Properly WIG builds or improvesthereon,viddthdoessuch work FIXTURES,PER TRAP 5.00 SDFT.FLO0RAREA TOTALACREAGE
himself m through his own employees,provided thus such improve-
mentsavemenot ntissoldor offeredwthinon yearsale.o however,the the o ne, GAS•EA.SYSTEM-1INC.4OUTLETS 8.00
Sar improvement is sold within one year of completion,the owner- GAS EASYSTEM-OVER 4 (EA) 200 BUILDING USE
builder will have the burden of proving that h - . . .
e did not build or im- RES IND CON PS Other
prove 1,as ownerose
utltheJ. INDUSTRIAL WASTE INTER. 30.00 ❑ 0 ❑ 0 ❑
❑ 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 ASSESSORSPARCEL NO.
and Professions Code:The Contractors 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 commctods)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,BAP.C.for this WATER HEATER W/VENT 6.00
reason
OwnerDat WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORI(FRS'COMPENSATION ECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofconsent to sel Ginsum, ZONING ENG SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-2a
Z Z 13 Certified copy is riled with the city inspection division. MISC.- REFER TO ORD.
0 Applicant Y C] N[] Y 0 NE]
G: Lo CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 7L00D ZONE A.L.U,C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLO,
0. a
(This Section need not be completed if the permit is for one TOTAL Y[] N Y❑ N�
L0 O hundred dollars(S 100)or less.)
I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,1 shall not employ any person in any manner so as to
0 W become subject to the Workers'Compensation Laws of California.
0. Date Applicant BUILDING q
>_ W NOTICE TO APPLICANT: If,after making this Certificate of E.- ALTER OR ADD TO MECH. 5.00 q
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
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000GF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000 C.FM.) 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.CJ, HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)Lender's Address 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 Willi all city and county g01LER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and slate laws relating to building construction, and
hereby authorize representatives of this city to enter upon the
above-mentioned properly for inspection purposes. BOILER-COMP Over 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,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
gran (t 'sp mit. y MECH.CONT. LIC.NO. MECH.
/!W Ayar TOTAL TOTAL G.z '�
(Sig ature of Applies Contra -)Sate
OFFICE COPY