9269 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES _ USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FI CATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT ��
ADDRESS
^,1,01 B 1 ING-ELECTRICAL-PLUMBING-MECHANICAL
CME
R S - PLAN CHECK VALIDATION
CAME QTY. ELECTRIC PERMIT FEE
,,114 0 PHONE
D TRFCTDR'
NA / UTLETS-SWITCHES-RECEP 10.00/1.00
S+�0 126t LIc.N LIGHTING FIXTURES 10.00/1.00
ro RACTORS PPLIANCES-RESIDENTIAL 4.00
DRESS
PHONE PANELS 10.00 T OF APPL ATION
ARCH ECT PANELS 200 AMP) 20.00 HECK FEE P.C.No.
AR
ENGINEER
uc.No. SIGNS TRANS. 3.00
ADDRESS ENG, 00 CIRCUIT 5.00 PERMIT VALIDATION
ZIP .EMP.METER OR POLE INS. 20.00 PA1p
APPLICANT MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 12 1995
o o LICENSED CONTRACTORS LhCLARATION TEMP.POLE 30.00 �s', _ J
u v I hereby affirm that 1 am licensed ander provisions of Chapter 9 IS A
a, UWkirbA
rt N (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. BCH.
D z Professions Code,and icmue is in full for�ce/'1 ✓✓ ( t ,� ❑ ❑ ❑
a o m- license Cluss�Lia Numher2L
Q w Date {{. vw��'' Contractor tel!/ fJ
xs BUILDING P RMIT
IS a w sc OWNER-BUILDER DECLARATION INFORM ION L
woa MISC.- REFER TO ORD
3 LL_ I hereby affirm that I am exempt from the Contractor's License VALUATION -
H .. o a Law for the following reason.(Sec 703 L5,Basin...and Profusions PERMIT ISSUANCE 10.00 $/FT.
Code:Any city or county which requires a permit to construct,alter,
2 ¢ Q Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
iL O LL inquires the applicant for swell permit to lite a signed statement that TOTAL PERMIT TO
n w m m he is licensed pursuant to the provisions of the Contractor:.,License
r z r Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
< Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
r es the basis for the alleged exemption.Any violation of Section 7031.5 5 RI TYPE CONSTR.
u by any applicant bar a permit subjects lire applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars I S500)J:
❑ I,as owner of the property.or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 O .GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Protessions DRAINS-FLOOR,ROOF,AREA,CON D. 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 y FIXTURES-PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such I.Prove-
m
mes are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, the owner GAS EASYSTEM-OVER 4 IEA) 200
builder will have th - . . .
e burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 E IND CON PB Other
❑ 1,as owner of the property,am 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 Contractors License Law does nal apply
to an owner of property who builds or improve,thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a conlractods)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ 1 i exempt under See.-,B&P.C.lar this WATER HEATER W/VENT 6.00 + +
ason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO,
WORK ISRS'COMI'IiNSAI'ION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent 10 set&insure' ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy th¢eof(Sec.3800,L.b.C.).
Policy No. Company
.Q ❑ CeJtified copy is byre is finished, FIRE SPRINK ENERGY T@4
Z Z �j�ErLific nv��'We8 with th• city inspection division.
O A leant ���1(�/.�JC. MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N❑
~ va - �� PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.c.
(14B HFICA' E Olt EXEMPTION FROM WORKERS'
W - COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y[:] N❑ Y [:] N[:]Z( This section need not he completed if the permit is for one TOTAL
hlmdreA doll...($100)or less.)
U O 1 certify that in the performmnce of the work I'or which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as 10
O W become subject to the Workers'Compensation Laws of California. <
n Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE "FO APPLICAM': If,after making this Certificate of Fs-
F" ? cmptioo,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=CF.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.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
HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OV ER 100,000 B,T.U.)9.50
Lender's Address ELECTRIC
I certily 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 to hoilding construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00
hereby autlmrlm representatives of this city to enter upon the BOILER-COMP IOve,100,000 BTU)SEE FEE SCH. MECHANICAL
above nsentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,jedgleals, Costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way uce a against said City in consequence of the
grant f lhi m' . MECH.CONT. LIC.NO. MECH.
y rorAL TOTAL
S a rco',APP 'aril/ ,RRNCtor ! T
INSPECTOR COPY