9171 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY AyI., 78/
BU LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
DD.unSG APPLICATION & PERMIT
ADDRESS
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
/i /e PNarvE
NAME ACTORS OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.No. LIGHTING FIXTURES 10.00/1.00
NTRADDRESCToes
AAPPLIANCES-RESIDENTIAL 4.00
ONE PANELS 10.00 DATE OF APPLICATION
nR NI CT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
' uc.No. SIGNS TRANS. 3.00
AARCH OR DDRESS ENG, SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH. f
a0 RESE .l
ar SERVICECHANGE 20.00 ,/6{/
0 o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 G a 0
a u I hereby affirm that 1 am licensed under provisions of Chaptcr 9 ISSUANCE DATE
H 3 H (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
s., o z Professions Code nA n license is in full(nae anti elle t. ❑ ❑ ❑
z O v - Licern'c Class /- LIC.Number
9 z 0 Dutc Contractor
¢ le f cora �L BUILDING PERMIT
¢ ¢ w a OWNER-BUILDER DF-CLARAT'ION
INFORMATION
wo¢ MISC.- REFER TO ORD
LL v, I hereby athr n that I am exempt from the Contractor's License VALUATION $/FT.
F LL o < Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
- Code:Any city or county which requiresa permit to construct,alter,
ac ¢ ¢ 2 improve,demolish,or repair any structure,prior Io its issuance,also ELEC.CONTR. LIC.NO. ELEC,
in
O LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
a w m he is licensed pursuant to the provisions of the Contractor's License
Uzi
Law(Chapter 9(commencing with Section 7000)of Divislun 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ °o the basis for the alleged exemplion.Any violation.[Section 7031.5 STORIES TYPE CONSTR-
aim by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.I 5.00
of not more than five hundred dollars(S500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do Ole work.and the structure is not
intended or oUemd for sale (Sec. 7044, Business and Prolissions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code'.'I'hc Contractor's License 1-uw docs not apply to an owner of
property who builds or improves thereon,and who docs such work F IXTUR ES-PER TRAP 5.00 SO.FT,FLOOR AREA TOTAL ACREAGE
• himself or through his own employees.provided Ihal such improvr
ments are not intended or Offered for sale.If,however the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 (EA.) 200
builder will have the burden of proving that he did not b - . - . .
uild or int- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ I,as owner of the property,um exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec 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'
Rod owner of property who builds or improves thereon.and who LAWN SPR INKLERS-OVER 5(EA.) 1.00
contracts for such projects
c Law.with a contractor(s)licensed pursuant to
the Contractor's License SEWER-SANITARY-STORM EA.200ft/10 00
TRACT N0, PARCEL N0.
❑ I um exempt under See. ,B.&P.C.for this ,WATER HEATER W/VENT 6,00
noon
Owner Dare WATER SYSTEM 5.00 ACC.DATE ACC,FILE NO.
W'ORKFRS'COMPFNSA'IION UE CLARA'FION WATER TREATING EQUIP. 5.00
I hereby a0inn that I have u certificate of consent to sell-inaue. ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE N0.
copy Olereof(Sec.3800.Lab-C.). -
Policy N�ja-/Sr- For �+r TA
O ❑ Certified copy va hereby urnished. w FIRE SPR INK ENERGY TQA
Al
Z O Ar_❑�'III copy is filed wit't a city inspectI V ivis( int, MISC.- REFER TO ORD. V ❑ NE] Y E] NE]
w 1���� PERMIT ISSUANCE 10,00
CHRTIFICATIi OPEAIIOTION 1'ROh1 WOR'F.RS' FLOOD ZONE a.L.u.C.
LU COMPENSATION INSURANCE P O.CONTR. LIC NPLG. ❑ ❑
CL 0 CL Z ('Phis section need not be completed if Oln permit is for one T / O. TOTAL V❑ N Y [:] N
hundred dollars IS 100)or less.)
U O 1 certify that in the performance of We work for which this pal- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued. I shall not employ any person in any manner so as to
O w become subject to the Workers'Compensation Laws of California. r BUILDING
a Date Applicant ALTER OR ADD TO MECH. 5.00
} to NOTICE TO APPLICANT: If,alter making this Certificate of Ex-
F 2 enlption,you should become subject to the 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 1g000C.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the Pcriormmnce 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 HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and stale that Om above VENTI LATION FAN (SINGLE) 4.00
• information is correct. I agree to comply with all city and eenmty PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP I3 H.P.Or 100,000 g.T.U.) 6.00 0
hereby authorize representatives of this city
In enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agyS to save, indemnify and keep harmless Ole City of MISC,- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in co asequence of the
graining of this permit. MECH.CONT. LIC.N0. MECH.
OTAL TOTAL
•nature o App icautivointraclof Date
INSPECTOR COPY