9110 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT ` 9119
ADDRESS
/ BUILDING-ELECTRICAL-PLUMBING -MECHANICA
/ 'S- A PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
'AW "A
NAMER"G R UTLETS-SWITCHES-RECEP 10.00/1.00
/i Lc.NO. LIGHTING FIXTURES 10.00/1.00
ADDRESS
ADDRs APPLIANCES-RESIDENTIAL 4.00
RESS Ess
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00, �
ARCO Ess ENG. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 t
APPL
MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
F o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
¢ u v I hereby affirm that I am licensed under provisions of Chaplcr 9 ISSUANCE DATE
w a a (commencing with Section 7000)of Division 3 of the Business and g G. ELECT. PLG. MECH.
r ¢ z Professions Code,and my license is in full force and effect. •0
z o w - License Class Lic.Number El
9 v,- Dole Contractor
a a BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DECLARATION
¢ u, u INFORMATION
wi LL I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
LL0j Law for the following reason.(See.703 1.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
-VA Code:An-City y
Q caieh u p tissal4q
Q improve,denlsh,or anstructure,priorto its issuance,a1SD
ELEC.CONTR. LIC.NO ELEC. v ✓ y
¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w he is licensed pursuant to tine provisions of the Contractor's License
Law(Chapter 9(commenciagwiWr Section 7000)of0ivisioir3 of thex
- a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
Y W r o the basis for the alleged exemption.Any violation c Section 7031.5 I STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civilpenaltyALTER-DRAIN&VENT-WATER (EA.) 5.00 of not more than five hundred dollars(8500),): _1„
❑ 1,as owner of the property,or m
p p y, work,
n d t ees with-wagesot BACK FLOW PROTECT.DEVICE 4.00 DOC.GROUP RES.UNITS
their sole r offered
for will(S the work,and the and
Pr re i9 not
intended or offered for sok(Seca 7044, Business eta Professions / DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractors License Law docs not apply to an owner of�
himselfpropertyor through
buildsorimproves employees, o does
such improve work FIXTURES-PER TRAP 5.00 so.Fr.FLooR AREA TOTAL ACREAGE
�� himself re through his own emredfor, le If.c`d that such improve-
. mems are not intended or offered for salt lC,however th;building GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
or improvement is sold within one year of co npleiioml9he owner- GAS-EA,SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not haild Ur im- RES INC CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 El ❑
❑ I,as owner of the property,am exclusively CoorlCtiog with 1:1 11 11
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code.'I he Contractor's License Law docs 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 contractor(s)licensv-d pursuant to SEWER-SANITARY-STORM EA.200E/10.00
tine Contractors License Law. TRACT NO. PARCEL NO.
D I am exempt under Sec.-,II for this WATER HEATER W/VENT 6.00
Person
Owner P Ad,-. VV.4o Date 4 WATER SYSTEM 5.00 ACC.DATE ACG FILE NO.
WORKERS'CCMPCNSATION DECLARATION WATER TREATING EQUIP. 5.00
I 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 NO.
copy thereof(Sec.3800,Lab.C.).
Policy N..-Co...pary
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is fled with the city inspection division
M ISC.- REFER TO ORD.
O Applicant YE:] NE:] YE] N�
~ w PERMIT ISSUANCE 10.00 FLOOD ZONE A.L:uc.
Lu CF;R'I'1 PIG OM IJP I AX IO1'INS PROM WORKERS'
W > COh1PfiNSATION INSURANCE PLG.CONTR. LIC,NO. PLG.
0 This Wdidn need not be cue ntplded if the permit is for one TOTAL Y❑ N Y[J N❑
hundred dollars IS 100)or less.)
0 O 1 certify that in lire performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
W F mit is issued,I shall not employ any person in any manor so as to
U become subject to the Workers Compensation Laws of California.
Ul Date-Applicant ALTER OR ADD TO MECH. 5.00 BUILDING X70 3�
} N NOTICE TO APPLICANT- If,after making this Certificate of Ex-
r z emplion,you should become subject to the Workers'Compensation APPLIANCE - 5.00 PLAN CHECK
provisions of tine Labor Code, you must forthwith comply with FEE-
CJ such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE.
I hereby affirn that there is a construction lending agency lot EXHAUST HOOD (WITH DUCT) 5.00
the PrHooH en,c of the work for which this permit is issued(So,, MICROFILM
3097,Civ.C.). H EATING UN IT ITO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)Lenders Address ELECTRIC
Ice'Dfythal l love read this application and sfit,tlml lire above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city-and county PLUMBING
t ordinances and state lows relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
herchy autm-mV representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save- indemnify and keep harmless the City of MISC.- REFER TO ORD.
u Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.001CONST.TAX
may in any way accrue against said City in consequence of the
g, large inspector. MECH.CONT. UC.NO. MECH.
\ n . x14/ //�/�'S TOTAL TOTAL o('
Stg ature of Applicant//Contractor � - � 3 2.
INSPECTOR COPY