9152 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS 915 2
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
D R'S PLAN CHECK VALIDATION
NAME S�7�f /I[� OTY. ELECTRIC PERMIT FEE
.T YQI I vHON
CTORS
NAME UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
LIC,NO. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADDRESS
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
ARCH.
DD ESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS / �,-
SERVICE CHANGE 20.00 /
Dec . LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
ar u I hereby affirm that 1 mm licensed under provisions of Chapter 9 tw ISSUANCE DATE
m a h Iconnnencing wish Section 7000)of Division 3 of Ihn Nosiness and BLDG. ELECT PLC. MECH.
H z Prof'anions Code,and my license is in full force and effect.
"z o as - License Class Lic.Number
o m - Date Contractor El I El
- sc x f BUILDING PERMIT
Ie ¢ w a OWNER-BUILDER DECLARATION INFORMATION
A 0 A0 MISC.- REFER TO ORD
w S LL H I hereby affirm that I am exempt from the Contractor's License VALUATION §/FT.
HLLoa Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00
m� Code:Anycity orcounly which requiresa permit tocnnstrucLalter, / C�s J
ce Q Q Q improve,demolish,or repair ally structure,prior to Its issuance,also ELEC.CONTE. LIC.NQ ELEG v V
Km LL requires the applicant for such permit to file it signed statement that TOTAL PERMIT TO
A w Ile is licereed pursuant to the provisions of the Contractor's License
H Z i
Law(Chapter 9(conlmencing with Section 7000)of Division 3 of the
a Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
'- T the basis for lheallcged exumplion.Any violation of Section703L5 WPE CONSTR,
e. 3`0 by any applicant for a Perm it subjects the applicant tO a civil penalty ALTER-DRAIN -WATER (EA.) 5.00 �p.
of not more than five hundred dollars(S500).):
LJ-
❑ 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 is not
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 docs such work FIXTURES-PER TRAP 5.00 SO.FT.FLOORAREA TOTALACREAGE
• himself or through his own employees,provided that such inurzovc-
mems are not intended or offered for sale.If,however.the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS-EASYSTEM-OVER 4 IEA) 200
builder will have the burden o1'proving that he did not build or int . . .
- BUILDING USE
prove to,purpose of sole.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ I,as owner of Ole property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contract.,, to construct the project(Sea 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
the Contractor's License law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,B&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner IV., 0 A4 A Date 7f WATER SYSTEM 5.00
ACC.GATE ACC.FILE NO.
COMI'I!N A'1'ION DECLARATION WATER TREATING EOUIP. 5.00
WORVI.'RS
I hereby w hon that 1 have a certificate of consent to sell-insure .ZONING
or a certificate of Workers'Compensation Insurance,or a cerlificd ENG.SITE N0.
copy Olereof(Sce.3800 Lab.C).
Policy No. Company
O 0 Certified Copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z O Certified copy is fled with the city inspection division.
MISC.- REFER TO ORD.
0 Applicant Y ❑ NE] Y ❑ N❑
CC y CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.O.
W > COS11'fiNSA'fION INSURANCE PLG.CONTE. LIC.NO. PLG.
a (Phis' section need nor be completed if the "coni( is for one ' TOTAL Y E] N[] Y ❑ N❑
hundred dollars IS 100)or lits.)
U O 1 certify that in lire performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
' LL I- mit is issued,I shall not employ any person in any omnnerso as to
Ow become subject to the Workcrs'Compenmlum Laws of California.
y Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING S-eJ1�
} W NOTICE TO APPLICAN'P: If,after making this Certificate of fix-
F 2 emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK 1J�
provisions of the Labor Code. you must forthwith comply with FEE /
(.J such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCI ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE ,.JU
1 hereby affirm that there's a constme(ion lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the pcHmmaric, of the work for which this permit is issued(See. MICROFILM
3097,Civ.C.). HEATING UNIT TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING ON IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
1 terrify that 1 have read this application andstate Ola(the uboce VENTILATION FAN (SINGLE) 4.00
• information is correct. I agree tojeonnply with all city'and county - PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize represc"latis'es of this city'( colo upon Ore BOILER-COMP (over 100.000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purpous.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs mm expenses which PERMIT ISSUANCE 10.00 CONST.TAX
nay,in any way accrue against said City in con,equence of the
gm I Ing of this permit. MECH.CONT. LIC.NO. MECH. t
TOTAL TOTAL
Si " tore � ph ant nntracl tc
INSPECTOR COPY