9124 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
BUILDING PROJECT I DENTIFICATI gppLICATION & PER
81111.DING � 9 2
ADOR E55
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
0 ER'S PLAN CHECK VALIDATION
NAME OTV. ELECTRIC PERMIT FEE
ONE
NAMEancroRs OUTLETS-SWITCHES-RECEP 10.00/1.00
•�i' CfJ /�S uc.No.t LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S APPLIANCES-RESIDENTIAL 11 4.00
/ ADDRESS +�
4(/0 I.ONaV PANELS 10.00 DATE OF APPLICATION
ogonTECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
NGINEER
LIC.NO. SIGNS TRANS. 3.00
ADD ESS Erva. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
ASr'a
ADDREDDRESSS MOTORS SEE FEE SCH. S
SERVICE CHANGE it 20.00
o¢ TEMP.POLE 30.00
2
r o o LICENSED CONTRACTORS DECLARATION
3
a ii� I hereby affirm that I am licensed under provisions of Chapter 9 '{ ISSUANCE DATE
1° (commencing with Section 7000)of Division 3 of the Business and
ti ¢ BLD . ELECT. PLG. MECH.
H m i Professions Code, nd Icense is in full fore t f t.
_o z w W License Class Lic.Number
D., Contractor Contncloryj
a Y E I BUILDING PERMIT
¢ ¢ ¢ OWNER-BUILDER D17CLARAI'ION
o or INFORMATION
R
g r I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO,ORD
m VALUATION $/FT.
r u o J Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a Permit to construct,alter,
2 a¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. /
O ac requires the applicant for such permit to file a signed Matement that b TOTAL PERMIT TO
a w m he is licensed pursuant to the provisions of the Contractor's License /
H z i
Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe
¢ Business and Professions Codel or that he is exempt Dterefrom and QTY. PLUMBING PERMIT FEE
fio
the basis for the alleged exemption.Any violation of Section malty STORIES TYPE CONSTR.
a3 � by not
applicant fora hundred
subjects lhcapplicam inacivil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(55001.1:
❑ I,as owner of lite properly,or my employees with wages as BACK F LOW PROTECT. DEV ICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do lite 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 nor apply to an owner of
properly 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 that such
improve-i,1 meats are not intended or offered for sale If,however,lite building GAS-EA.SYSTEM-1 INCA OUTLETS 6.00
or improvement i 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 int- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 E IND CON PB Omer
❑ 1,as owner of the Property,am exclusively contracting with D ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and ProfesMons Code_The Contractor's Licensc Law does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
COnlroe s ,it such projects with a contractuno licensed pursuant to
Y {, lite Contractors License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ IamexemptmWer Sec. ,B.&P.C.lilrlllls WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00} ACC.OATE ACC.FILE N0.
A\ WORK FRS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
�- f\ hereby affirm that 1 have a certificate ofconsent to self-insure. 20NING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
1 thc,,.f(Sec. S?,O ab .1.
ef
r Ifofyisfre y
❑ Certified copy is ere yfurnis red. FIRESPRINK ENERGY T 24
'N- z Z1 ❑ Certil'icd copy is filed with the city inspection division.
�. FO Applicant Iv,SG.- REFER TO ORD. v [] N� vE] N[:]
� N
CER'I'I FICA1 EOF EXEM PTION FROM WORK ERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W D COMPENSATION INSORANCE PLG.CONTR. LIC.NO. PLG. V N Y N
d n
�
h. o (This section need not be completed if the permit is for oe TOTAL
::) Z hundred dollars(S100)or less)
U O 1 certify that in the performance of the work Ibr which this pct- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
I, UL F mit is issued,I shall not employ any person in any munncr so as to
r Qw become subject to lite Workers'Compensation Laws of California.
0. Datc Applicant BUILDING 60
N NOTICE l'O APPLICANT': If,after making this Certificate of I:x- ALTER OR ADD TO MECH. 5.00
F Z emption,you should become subject to the WorkersCompensation APPLIANC 51
00 PLAN CHECK
provisions of lite Labor Code, you must forthwith comply will
U such provisions or this permit Shull b ccmcd rcv"jL� IR HANDLIN UNIT(TO ig000C.F.M.) FEE `
CONSPf4L[ffl NIjfNinsfir AI .ANDLJNGU IT, VER1 "0 SEIS�IC`EE
hcrcby often%�/,,. �^ a coretru [( In p ugcn r ��'EX AUST H OD ITH DUCT) 5.00"
the perfonnanec f the work for which this pen tl a Isx(J ee MICROFILM
3097,Civ.C.l. HEATIN UN �0 rB. ;U.1 8.00
( Lender's Name HEATING IT(OV 1 ,0 8 0
Lender's Address ELECTRIC
I'
Icertify that l have read this application and stale thatihe' ove VENTI LATION FAN (SI NG LE) 4.00
10 I'll ion is correct. 1 agree to comply with all city amid
county PLUMBING
ordinances anJ Mate Taws relating to building construction, and
BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hcrcby authorue representatives of this city to enter upon ih° BOILER-COMP IOver 100,000BTU)SEE FEESCH. t.. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save. indemnify and keep harmless file 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 consequence of the _s
granting of this permit MECH.CONT, LIC.NO. MECH.
TOTAL / � /i!•'I
TOTAL
I onfractor Da
l INSPECTOR COPY