10857 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY '
'BUILDING PROJECT IDENTIFICATION PERMIT NUMBER `
OU
LDING APPLICATION & PERMIT
AooREss rVC� BUILDING--ELECTRICAL-PLUMBING-MECHANICAL 10 8 5'7
• '-PLAN CHECK VA LI DATION
NAME • QTY. ELECTRIC PERMIT FEE
'
PHONE
CONT TOR I OUTLETS-SWITCHES-RECEP 10.00/1.00
NA 4 -
ofLIGHTING FIXTURES 10.00/1.00
roNTRACTOR'S APPLIANCES-RESIDENTIAL 4,00
ADD sJ$�/
PANELS - - 10.00 DATE OF APPLICATION
ARCHITECTPANELS (OVER 200 AMP) 20.00 PLAN. CHECK FEE P.C.NO.
OR . P
ENGINEER ,D
- �' •v LIC.NO. - SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT - 5.00 PER p�ILv�AuonnoN -
ZIP EMP:METER 08 POLE INS. 20.00 f ED / 188
APPLICANTS MOTORS SEE FEE SCH. ICS
AooREss • city, a(SERVICECHANGE 20.00 Cu {I R.B►fIf10"
woo LICENSED CONTRACTORS DIiCLARATION •-
Q�0 1 hereby affirm that I am licensed order provisions of Chapter 9 "noFISSUANCE D
N er w (commencing with Section 7000)of Division 3 of the Business and _ 10� RLDG: ELECT. LG. I MECH.
H w z Professions Coy an license is in full fo�ryndM
z O w - License I`s_L_Z' Con racon
tor sQ-�/CJ ❑ ❑ ❑
O - Dale
Contractor \� '
- 2, -3
w a OWNIi R-BUILI)IiR DF BUILDING PERMIT
o A " MISC.- REFER TO D INFORMATION
X ; u y 1 hereby affirm that I am exempt from the Contractor's License . VALUATION S/FT.
HLL04 Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE - 1 GT.00
Code:Any city or counly which requires it permit to constnmt;alter, -
improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. ,
O u requires the applicant for such permit to file a signed statement that TOTAL P MIT TO
A w m he is licensed pursuant to the provisions of the Contrectois License
H to va Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a Business and Professions Code)or thathe is exempt therefrom and QTY. PLUMBING PERMIT FEE
$ the basis fur the dlleged exemption.Any viola,ion of Section 7031.5
STORIM TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) $.00
of not more than five hundred dollars($5001.): -
❑ I,as owner of the property,ormy employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensalion,will do the work,.and the structure is not -
intended or offered for sale (Sec. 7044, Idusiness'and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
�r property who builds Or improves themon,and who does such work FIXTURES,-PER TRAP 5.00 SO.FLFLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered lot sale:It,however,the building GAS-EA.SVSTEM•11NC.4OUTLETS 6.00
1 or improvement issold within one year of completion, the owner- GAS-EASYSTEM-OVER 4 (EA.) 200 BUILDING USE
builder will have the burden of proving that he did not build or int' GAS . .
' RES, IND CON PB Omer
prove for purpose of sale.). - INDUSTRIAL'WASTE INTER. 30.00 11 1:1 1:1 El 11❑ I,as owner of die property,am:exclusively contracting with
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-I.INC 5 Y.B. 6.00 - ASSESSORS PANGS L NO.
and Professions Code: rhe Contractor's License Law does not apply
to an owner of properly who builds or improves thereon,and who ILAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts forsuch projccawitho contractors)licensed pursuant to SEWER-SANITAR V-STORM EA.200ft1 .00
the Co ntruclor's License Law. 10TRACT NO. PARCEL NO.
❑' I ant exempt under Sec. ',B.&P.C..far this WATER HEATER W/VENT 6.00 -
reason
Owner Die WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
q+�Iic+ n IRA'HON � WATER TREATING EQUIP. 5.00
hereby affirm that I have a cerl{licatl•O nit to self-insure. ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sec.3900,Lab.C.). Q
Policy No. .ompany -
,q Cart Ii d op Is her I mshcd. ,' FIRE SPRINK ENERGY T 44
Z 2 /��al cerN py illi tl cit nspection division. - MISC.- - REFER TO ORD. ❑ ❑ ❑ ❑
O Applicant G v N v N
Hy - PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C. -
CC CIiR'rIFICArE01 EXEMI'TIO tOM WORKERS'
W > COMPENSATION I RANCE PLG.CONTR. u0.NO. PLC. ,
C O (This section need not be completed if the permit is for one - TOTAL v❑ N❑ v [3 NCD
Z hundred dollars(S 100)or less.)
U O I certify that in the performance of the work for which this per, CITY, MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any manner so as to _
U become subjectlo the Workers'Compensation Laws of Callfontla.,
O y Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} w NDTICI,TO APPLICANT:-If,after making This Certificate of fx
♦- ? 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
such provisions or this permit shall be deemed revoked. AIRjHANDLING UNIT(TO 10=C-F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10000C.RM.) 6.00 SEISMIC FEE '
I hereby affirm that 11 ere is na a wcotldsnstruction lending agency for EXHAUST HOOD(WITH DUCT) _ 5.00
the perfornia nen Of th- ark Ihich permit is issued(Sec. MICROFILM
3097,CIv.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name (1/1>.�
Lender's Address • - HEATING UNIT(OVER 100,0008.T.U.)9.50 ELECTRIC
certify that I have read this application and state that the above VENTILATION FAN (SINGLE) .'r 4.00
information is correct. I agree to comply with all city unit county PLUMBING
ordinances and state laws relating to building construction, and 'BOILER H.P.or100,000B.T.U.) 6.00
hereby authorize representativesofthis city to tenter upon the BOILER-COMP (Over 100,000 STU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.' •.
(We) agree to,suve, indemnify and keep harmless the City of MISC- _ REFER TO ORD. '
Cupertino against liabilities,judgments, costs and expenses ImicI CONST.TAX
may in anyway , rue a in said ity ' conseyo m PERMIT ISSUANCE '10.0.0
granting- IL' dL '� i6 I t MECH.CONT. LIC.NO. MECN.
roTAL TOTAL
S,.14f of pplicam/C tract r Datc -
• -OFFICE COPY -