9503 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
q ,oq,Ns APPLICATION & PERMIT 9503/r l � BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
I OwNER'S C l PLAN CHECK VALIDATION
"AMS QTY. ELECTRIC PERMIT FEE
PHONE
• NAMERAcrn/R s, OUTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
CONTR LTOR's
ADORES 3/c'T APPLIANCES-RESIDENTIAL 4.00
F
} HONc PANELS 10.00
7 0'234 DATE OF APPLICATION
ORCHITEC, - PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRESS ENG, PERMIT CIRCUIT 5.00 PERMIT VALIpATION
ZIP FrEMP. METER OR POLE INS. 20.00
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
° ¢z
Foo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
H w (commencing with Section 7000)of Division 3 of the Business and
a A - BLDG. ELECT. PLG. MECH.
F w z Professions Code,and my license is in full fore•an effe L. ❑ ❑
Z0
m - License lass Li c.Number
9 m r w� Date - Contractor
Q y f J
¢ ¢ a OWNER-BUILDER DECLARAT'ON BUILDING PERMIT
a o d U INFORMATION
w g; H I hereby affrm'tbat I am exempt from the Contractor's License MISC.- REFER TO ORD
LL O a Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
� - J Code:Any cityorcounty whichreyuiresapernin mconstruct,alhv,
Q ¢ p improve,demolish,or repair any structure,Prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
¢ requires the applicant for such permit to file a signed statement that < TOTAL PERMIT TO
A w ro ou i
he is licensed pursuant to the provisions of tire h e ContractoLicense
Hzi Law(Chaptq 9(commencing with Section 7000)of Division 3 ofthe -RL 0,411 ,tI
P o Business and Professions Code)or chat he is exempt therefrom and CITY. PLUMBING PERMIT FEE LT
tl,6 basis for the alleged exemption.Any violation ol'Snclmu 7031.5 1, STORIES TYPE CONSTR.
ro a.. 3m by any applicant lot apermit ittljeds lire applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
` of not more than five hundred dollars(S500).).
❑ h as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
,f 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,AR EA,COND. 5.00
Code:The Contractors License Law does not apply to an owner of
Property who builds 0r improves thereon,and who does such work FIXTURES-PER TRAP, 5.00 SO.FT,FLOOR AREA TOTAL ACREAGE
himself or chronic his own employees,provided that such improve-
menuare not intended oroffered for sale.IL however.the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion.0,e owner-
builder will have the burden of proving that he did not build or int- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose ofsale.l. \ INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ 1,as owner of the property,am exclusively contracting with 0 ❑ ❑
licensed contractors to construct the project(Sec 7044,Business LAWN SP INKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's Licinow 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 conlractods)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/10.00 /Q TRACT NO. PARCEL NO.
rl a❑ I am exempt under Sec B,4P.C.for this WATER HEATER W/VENT 6.00
I 111
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'CO.MPENSA'I'ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate ofconscot to self-insure, - ZONING ENG.SITE N0.
or u certificate of Workers'Compensation Insurungc.orT�flcd +
alpy thcrcof(Sec.3x00,Lah.C.)/too .0 $',y-�/ ii 7
Policy No. Company
O ❑ Certified copy is hereby furnished2
W I FIRE SPRINK ENERGY T 24
Z Z J ❑ Certified copy is Rled with the city Imp ion division. MISC.- REFER TO ORD.
OJ npphcanl Y❑ N❑ Y ❑ le
cc N s' CIiRTl1'IGA'I'1i OIr EXIib1Pf ION PROM WORKERS' PERMIT ISSUANCE 10.00 O FLOOD ZONE A LSU!' .
W 3 C(/MPENSAI']ON INSURANCE PLG.CONTR. LIC.NO. PLG. ]d �- Y[:] N❑' N�
d O IT In, aeclum need not be completed if the permit is for one TOTAL O�
Z hundred dollars(S 100)or less.)
U O 1 certify that in the performance of the work for which this per- FEE SUMMARY
LL f- mit is issued, I shall not employ any person in any manner,"'as to CITY. MECHANICAL PERMIT FEE
O W become subject to the Workers'Compem,1110n Laws of Calitornia.
Dale Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>_ w NOTICE TO APPLICANT: If,after making this Certificate of Ex.
Z F emption,you should Income subject to the Workeri Compensation_ APPLIANCE 5.00 PLAN CHECK
provisions the Labor Code, you must forthwith comply with FEE
U such provisioio ns or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000QF.M.) 4.00
CONST RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p00GF.M.) 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 H EATI N G U N IT(OVER 100,000 B.T.U.)9.50
Leader,Address ELECTRIC
I certify that i have read this application and state that 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 I0 building ma"Octron, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 �G
hereby auchoriee representatives ec this city lu enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
herebynemlioned property forinsp of this
purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
May n any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
gr t , of this permit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
$ignut a re of Applicant/Conlin r Date -
INSPECTOR COPY
I