9153 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT 9153
PDDRE55
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
O rvE 'S PLAN CHECK VALIDATION
NAME QTY.
NAME ELECTRIC PERMIT FEE
PHONE
RA s OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.R. LIGHTING FIXTURES 10.00/1.00
CON
ADDRESSTRA �/
rs A-1 .415-fy1S ppLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
cHITECT
OR PANELS (OVER 200 AMP) 20.00 PLANCHECKFEE P,C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 V
ADDRESS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 wsf
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
IT u u I herchy affirm full 1 am licensed under provisions of Chapter 9 j ISSUANCE DATE
v~i 1 vAi lc'omntencing with Section 7000)of Division 3 oC Da Business unA
D BLDG. ELECT. PLG. MECH.
F z Professions Code,and my license is in full force and effect ❑ ❑ ❑ ❑
Z o m - License Class�__z t.a.�Lica Numb,,,
o r o Dote/--,-�-'-��1-'/ Contractor
a r BUILDING PERMIT
¢ a OWNER-BUILDER DECLARATION
R o a"t I am exempt from the Contractor's License MISC.- REFER TO ORD INFORMATION
w g y I hereby affirm that
H .. oa Law Corthe following reason.(See.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
Code':Any city or county which requires a permit to construct,alter, / �jO
¢ a O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. (O o
- DLL requires life applicant for such permit to file a signed statement that TOTAL PERMIT TO
w m he is licensed pursuant to the provisions of the Contractor's License
rzi
Law(Chapter 9(Commencing with Section 7000)ofDivision 3 ofthe SiG�
i x o Ihcsiness unit Professions Code)or that he is exempt therefrom and OTY. - PLUMBING PERMIT FEE ��VV
¢ 1 o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollar,($500).):
❑ 1,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 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 does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
Y • himself re through his own employees,provided that such improve-
mcntsarc not through
or employees,ffered for provided
that s,thcn.....g GAS-EA.SYSTEM-1INC.4OUTLETS 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 that he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB One,
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors ri construct life project(Sec 7044.Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:1'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 cmUractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ftI10.00
the Contmeoi s LicentC Luw. TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-,BAP.C.let this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.F14 N0.
WORK 17RS'COMPENSATION UECLARA'I'[ON WATER TREATING EQUIP. 5.00
h, I hereby affirm that I have a Certificate of consent to Self-insure. ZONING ENG.SITE NO.
or a Certificate of Workers'Compensation Insurance,or a certified
copy Omreof6ec.3800,Lab.C.).
l Policy No. Company
0 ❑ Certified copy is hereby fumi5hcd. FIRE SPRINK ENERGY T-24
z Z Cerrfa, upy red withI PERMIT ISSUANCE 10.00 Dhc cit Inspection division.
O I;calht MISC.- REFER TO ORD. YE] NE] v ❑ N[3F-
LU w CIiRTI PICAl'I!O F SAEXEMPTION PROM WORKERS' FLOOD ZONE A.L.U.C.
'W > � COMYISNSATIOION INSURANCE I,
CONTR. LIC.N0. PLG.
CL Z (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ NEI
hundred dollars 1$100)or less.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
W H mit is issued, I shall not employ any person in any manner so us to
O become subject to the Workers'Compensation Laws of California.
t � 0. Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING /3-i } W NOTICE TO APPLICANT'. If,after making this Certificate of Ex-
H ? curptlan,you should heroine Subject to lire Worked Cont pemmtioll APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE T`y
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=C.EM.) 6.00 SEISMIC FEE
/v I herchy,e(firin 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
Conder',Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
'
bcenil'y that I hm'c read fills application and slate Dom the above VENTILATION FAN (SINGLE) 4.00
-: information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction. and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby maim ire representatives of this city to enter upon the BOILER-COMP elove,100,000BTUISEE FEESCH. MECHANICAL
above property for inspection 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 a acme against s "d City in consaryenre of flue
gr ROD,of s1 onll. MECH.CONT, LIC.NO. _ MECH. q _
TOTAL TOTAL
iR a /Cont ttor D le
INSPECTOR COPY
I