0918 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI_ POINT EN ONLY
BU I LDING PROJECT I DENTIF[CATIONPERMIT NUMBER
aLDDRESS ILOING APPLICATION & PERMIT 0 918
A �-'
BUILDING- ELECTRICAL-PLUMBING-MECHANICAL
OWN A'S • _ - PLAN CHECK VALIDATION
"AME I QTY. :; ELECTRIC PERMIT - w s g' FEE'a�
HONE ie_ .SMI''
D TRA TORS UTLETS-SWITCHES•RECEP 5.00/1.00
N E
IC.NO. LIGHTING FIXTURES 5.O0I1.00
no AAa
CONTRACTOR'S A- PPLIANCES-RESIDENTIAL 4.00
A DRESS `A.,
PNONE - PANELS 5.1111 DATE OF APPLICATION
ARCHIT CT 6.1111 PLAN CHECK FEE P.C.NO.
OR SIGNS
ENGINEER se3.00
LIC.No. SIGNS TRANS.
AROH.OR ENG. S.DD PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT
ZIP ITEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE ffira 10.00
Doo LICENSED CONTRACTORS DECLARATION
u u 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
IQ-I w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
HQN
0 i Professions Code an license is in full fort and of ct ❑
License Class Lic.Number WE ❑ ❑ ❑
m r J Dale Contractor
'0• ,- BUILDING PERMIT•,.8:-,`,-J
IZwu OWNER-BUILDER DECLARATION '_4_-s.INFORMATION '.)>;,.r,;.
0 s, 1- I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
w P -VALUATION S/FT.
w07 Code:Law Any following or county which
a permit town Professions PERMIT ISSUANCE . OP
va Code: e,demyorcounty wNch requimapermittoconsuance,also
Q Q improve,demOhah.Or repair any structure,prior l0 its issuance,a150 ELEC.CONTR.
LIC.NO. ELEQ
S O LL requires the applicant for such permit to File 0 signed statement that TOTAL PERMIT TO
m $ss he is licensed pursuant to the provisions of the Contractor's License .
F i Q
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe '✓�I'1'f , :;
Business and Professions Code)or that he is exempt therefrom and OTY hf , `' LUMBING PERMITy I• FEE ='
(E I- the basisforthe alleged exemption.Any violation ofScction703I.5 _ ;- �=1�.:�. .,."e e.'T.- 1 �ty ,5..:^' t!••='s< STORIES 6IfYPE CONSTR.
i ;•. by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(SS00).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE. 2.00 ooe.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. 4.00
Code:The Contractors License Law does not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES,PER TRAP 4.110 SO.FT.FLOOR AREA TOTAL ACREAGE
map"arself e
not hrough
de ownemployees,fors,pe.If.however,
ever,hat the
improve. GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
menti are not intended or offered for sale.U,however,the building
or improvement is said within one year of completion,the owner- GAS•EA.SVST EM-OVER 4 IEA.) 1.00 BUILDING uSE
builder will have the burden of proving that he did not build or im- RES IND CON PB Orner
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ 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. 5.00 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 IEA.) 1.00
contracts for such projects with a contracto"s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec---BAP.C.for this WATER HEATER W/VENT 4.00
rce0
Dale Owner WATER SYSTEM 4.00 ACC.-DATE ACC.FILE NO.
W'ORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certiftc.1,of consent to self-insure, ZONING ENG.SITE NO.
or a'certificate of Workers'Compensation Insurance,or a certified
copy Ihamc. 00,Lab.C.).
Policy Nd.}@$ ompany ') le
0 ❑ Cert ed co s hereby furnished. FIRE SPRINK ENERGY T-24
Z Z O Ce i d y is J ith t I, y ins Fiction division.
O Applicant MISC.- REFER TO ORD. Y❑ Nv ❑ N❑
F' ua PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.0 C.
TIFICATE OFE FTIONF OM RKERS'
LU > COMPENSATIONINSUR N PLG.CONTR. sec.NO. PLG.
tl O section ction need not be completed if the permit is for one TOTAL Y❑ IN CC] Y❑ N❑
::) Z hundred dollars IS 100)or less.) -, . :. ••- -
L) O 1 certify that in the performance of the work for which this per. t ° +t; ` e. ;' FEE SUMMARY
LL {- mit is issued,1 shall not employ any person in any manner so as to GTYs � MECHANICAL PERMIT`a 4 FEE : •S4 ,.•.):
U become subject to the Workers Compensation Laws of California.
C.
Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex - .
2 emption,you should become subject to the Workers Compensation APPLIANCE 4.00 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 10,0MCRIA) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNITIOVER 10=11F.M) 5.00 SEISMIC FEE .JrQ
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD IWITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT IOV ER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that l have read this application and state that the above VENTILATION FAN ISINGLE) 3.00
information n correct.1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building lconstruction,d co andmy BOILER-COA4P(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over iD0,0008TU)SEE FEESCH. 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
ma any ay accrue against said City in consequence of the PERMIT ISSUANCE 3.00
nti gal. i MECH.CONT. UC.NO. MECH. - -- -
TOTAL 'av
TOTAL...
S lumof Appll anljConUac r Uam -
OFFICE COPY �•L / � _q�}