9111 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENT(FICATION
PERMIT NUMBER
BUILDING APPLICATION & PERMIT 9111
ADDRESS
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
AWN R's - PLAN CHECK VALIDATION
NAM �7 f QTY. ELECTRIC PERMIT FEE
HONE 7111-,P 1
NAMEA S OUTLETS-SWITCHES-RECEP 10.00/1.00
UC.NO. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR (T.1
a APPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
ORCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIG.No. SIGNS TRANS. 3.00
ARCHE OR ENG. - SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP fTEMP.METER OR POLE INS. 20.00
Ars
ADDRESS MOTORS SEE FEE SCH.
UHEss
SERVICE CHANGE 20.00
0 o O LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
¢ o U I hereby affirm that I am licensed under provisions ol'Chapter 9 ISSUANCE DATE
Q n t
m
(comencing with Section 7000)of Division 3 of the Business and
BLDG. ELECT. PLG. MECH.
r A z Professions Code,Intl my license is in full force and effect ❑ ❑ ❑ ❑
o
o m u License Class-Lic.Nun.her
Duro Contractor
a r F BUILDING PERMIT
¢ ¢ ¢ OWNER-BUILDER DECLARATION (-
O to D MISC.- REFER TO ORD INFORMATION
K
g y I hereby attirm that I am exempt from the Contractor's License
u 0 Q Law for the following reason.(Sec.7031,5.Businessand Professions PERMIT ISSUANCE VALUATION §/FT.
r - Code:Anycity orcounly which reyuirasa permit toconstruct alter,
¢ to ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEG
u w m ¢ requires the applicant fur such Permit Io file a signed statement that TOTAL PERMIT TO
he is licensed Pursuant to to Provisions of the Contractor's License
Hsi Law(Chapter9(comntneing will.Section 7000)o f Division 3 of to
i o Business and 1'rufcssionS Code)or that lie is exempt therefrom and QTV. PLUMBING PERMIT FEE L-L�
¢ I- o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a3 _a by any applicant for a permit subjects the applicant ton civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
O 1,as owner of the property,or my employees with wagesas BACK FLOW PROTECT. DEVICE 4.00
Ihcir sole compensation,will do the work,and the nruclure is not OCC.GROUP RES.UNITS
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
himself re trough his own eared fors,provided that such iaiprove-
mentsarcnolinghhis oroffereoyeesalclLed thatrthchwilding GAS-EA.SVSTEM-11NC.40UTLETS 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 ofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON Pa Oma.
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sea 7044, Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Coda: No 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 fSr such projects with it contrucrots)licensed pursuant 10
the Contractor's License Law, SEWER-SANITARY-STORM EA:200ft/10.00 TRACT NO. PARCEL NO.
❑ lame rept udernSec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
on
cp
Owner Da - WATER SYSTEM 5.00 ACC.OATE ACC.FILENO.
WOiRS'COMPENSA1']ON DECLARATION WATER TREATING EQUIP. 5.00
I hereby al first (bat I have a cc,titicate of consent to w1finsure. ZONING ENG.SITE N0.
ertificate of Workers'Compensnion Insurance,or a certified
copy�thereat(See.3800,LaDCA
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z O Certified copy is Filed with the city inspection division.
O Applicant MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
CC = CER'1'IPICATE.OF EXEMPT ION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
L COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
(P
his section need nor be completed if thx one
e permit is fiTOTAL YE] [:] N
N❑ Y
Z ❑
hundred dollars IS 100)or less.) bawl
U 0 1 certify that in the performance of the work for which this per- QTY. MECHANI A PERMIT FEE FEE SUMMARY
L F mit is issued,1 shall not employ any person in any manner so as to
O w become subject to the Worker,'Compensation Laws of California.
Date Applicant - BUILDING
} y NOTICE 1'0 APPLICANT'
: If,after making this Certificate of fix- ALTER OR ADD TO MECH. 5.00
F Z cnhprion,you should become subject to the Workers'Conhpensarion APPLIANCE 5.00 PLAN CHECK
provisions of the labor Code, You moil forthwith conn Ply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MCF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000C.EM.) 6.00 SEISMIC FEE
I hereby affirm 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 HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lenders Address ELECTRIC GLV
I certify that l have read this application and state that the uhove VENTILATION FAN (SINGLE) 4.00
• information is correct. 1 agree to comply with all city and county PLUMBING
ordinances and stale laws relating (a building consiruclion, and BOILER-COM P(3 H.P.or100,000B.T.U.) 6.00
hereby authorize representatives of this city' m unser upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless tln City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
- may in any way acerae against said City in conse9acnce of the PERMIT ISSUANCE 10.00
•run tin of this pct 'L MECH.CONT. I- LIC.NO. MECH.
\ TOTAL
TOTAL
Jl ignatu of App ice n cto
oar Date
INSPECTOR COPY
I