11839 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER,
BUILDING
APPLICATION & PERMIT
f� a oRE s _,�r!_�` BUILDING =.ELECTRICAL-PLUMBING -MECHANICAL 11839
O R' G PLAN CHECK VALIDATION
NA,ME- OTY. ELECTRIC PERMIT FEE
w�
O PHONE
CONTRACTOR NAME UTLETS-SWITCHES-RECEP 10.00/1.00
•Am-&4LIGHTING FIXTURES 10.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
aDDRE55 II
C 45 4� PHONEJ!J PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc,NO SIGNS TRANS. 3.00
ARCH.ss ENG' SPECIAL CIRCUIT S.QQ PERMIT VALIDATION
ADDRZIP EMP.METER OR POLE RJ 20.00
APPLICANT'$ MOTORS SEE FEE.SCH. n
ADDRESS
SERVICE CHANGE�Ep 0.00
GO LICENSED CONTRACTORS DECLARATION
¢ u cl� of I hereby affirm that I am licensed under provisions of Chapter 9 U♦t ISSUANCE DATE
ya w (commencing with Section 7000)of Division 3 of the Basin ss and BLDG. ELECT. G. MECH.
F w z Professions Cod• an�j license is in full for' ❑ Eli o m License Classl_ Lic.Number ❑
o z w Date Contractor
BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DECLARATION
¢ u, u - INFORMATION
F
0 u H I hereby affirm that I am exempt from the Contractors License Mist.- REFER TO ORD
LLOa Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
Code:Any city or county which requimsu permit la conslnwt,al[eq
m a ¢ FO improve,demolish,or repair any structure,prior to its issuance,also ED DONTR. LIC.N0. ELEC. Dv�
o u requires the applicant for such permit to file a signed statement that CHID y TOTAL 1 PERMIT.TO
e w m he is licensed pursuant to the provisions of the Contractor's License
r s- Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
E i ao Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢F$ the basis for the alleged exemption.Any violation of5ection 7031.5 STORIES TYPE CONSTR.
aI_- by any applicant for a permit subjects the applicant ton civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(8500).)',
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECTDEVICE 400
their sale compensation,will do the work,and the structure i . .
s not OCC.GROUP RES.UNITS
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 dues such work FIXTURES-PER TRAP 5.00 s0.Fr.FLooR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintended or offered for sale If,however,the building GAS-EA.SYSTEM-11NC.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 t1u,he dill not build or im, BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER30.00 RES IND CON PB Othel
❑ 1,as owner of the property,am exclusively contracting with . ❑ ❑ ❑ ❑ ❑
licensed contractors to construct Om pinjecl(See.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 contractors)licensed pursuant to SEWER-SAN EA.200ft/10.00
the Contractor's License Law, TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO,
WORKERS'COMPENSATION D17CLARA'rION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE N0.
copy fl erllr ft Lab.C. Y R,t
Policy Nad_71�fpmpany. W S C6
❑ Cerlilled copy is her flrnished. FIRE SPRINK ENERGY T-24
Z Z 01Certified cc it �i city inspection division. MISC.- REFER TO ORD.Applicant Y ❑ N❑ Y ❑ N❑
~vN5 QR I :ICA1 k OF FXEMI'TN FROM WORKERS' PERMIT ISSUANCE 10.00 C
Lr - ER'I' 'ICA1'k OF EXEMPTIOFLOOD ZONE A.L.U .
W - COMPF-NSA'I'ION INSURANCE: PLG.CONTR. LIC.NO. PLG.
CL aZ (This section need not be completed if the permit is for one TOTAL Y❑ N [D N
❑ Y ❑
hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mil is issued,I shall not employ any person in any manner so as to
Q W become subject to the Workers'Compensation Laws of California.
Date Applicant BUILDING
a ALTER OR ADD TO MECH. 5.00
} W NO'T'ICE TO APPLICANT: It,after making this Certificate of Ex-
F 2 emption,you should become subject to lire 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.M) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10)000C.F.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.) HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name H EATING UN IT(OVER 100,000 B.T.U.)9.50ELECTRIC
Lender's Address
. I 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 PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon lireaboveBOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
hereby
authorize
ned properly for inspection of
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 a against said City in consequence of the
grunting ofihis pe lit. MECH.CONT. LIC.NO. MECH.
6 TOTAL TOTAL
i at of Applicant/Conractor Date
OFFICE COPY ,