9178 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT I DENTI FICATI ON PERMIT NUMBER
ADDRESS APPLICATION & PERMIT 9178
BUIL Ess
�650BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S I PLAN CHECK VALIDATION
NAME CITY. ELECTRIC PERMIT FEE
ONE
CON
AcroRs UTLETS-SWITCHES-RECEP 10.00/1.00
7` N . LIGHTING FIXTURES 10.00/1.00
RACToDTms J
Se
ADDRESS APPLIANCES-RESIDENTIAL 4.00
AO
•� vHONE2&7 PANELS 10.00 DATE OF APPLICATION
pp 1 C PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
uc.No. SIGNS TRANS. 3.00
ARE H.OR
ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP rrEMP.METER OR POLE INS. 20.00
ASNrS
ADDRESS MOTORS SEE FEE SCH. n
l I
SERVICE CHANGE 20.00 �/(7
00 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
rt v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANC€DATE/(Q
y a N( conuneneing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F o z Professions Code,and my license is in full force and effec ❑
zow License Class Lie.Number G/ f
o F Date i -Contractor
a y E J BUILDING PERMIT
¢ 0 n OW'N I:R-d UILDF.R DECLARATION INFORMATION
m 3 u m firm I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
Law for the following reason.(Sec.7031.5,Besmessand Professions PERMIT ISSUANCE 10.00 VALUATION g/FT.
Cade:Any city or county which requires a permit to construct,alter,
le a, Q Improve,demolish,or repair any structure,prior to Its issuance,also ELEG CONTR. LIC.NO. ELEC.
w-o a requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
se he is licensed pursuant to the provisions of the Contractors License
H z ¢ Law(Chapter 9lcommcncing with Section 7000)of Divis'ion3ofthc
4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE /E/2 G /v<
the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a. ; ,. by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN& VENT-WATER IEA.) 5.00
of not more than five hundred dollars(3500).)'.
❑ I,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 F IXTUR ES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself orthroughintended
ownemployees,for sale.
If.ed that however,
improve- GAS-EA.SYSTEM-1 6.00
counts um nut in is sold vv thin I,for solo.If.however,the building
or improvement rs sad within one year of completion,the owner. GAS EASYSTEM OVER 4(EA) 200 *t
builder will have the burden of proving that h - . - . .
e did not build or ire- BUILDING USE
prove 1,a'. 'let oftale.). INDUSTRIAL WASTE INTER. 30.00 0 IND 0 PB Omer
❑ d as owner rs the construct
ani exclusively , 7044,1 ing 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 Contractor's License Law does not apply
.. to ailtr owner of property who builds tr improvesthereon.l and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such censers with a cpnrructor(s)licensed Pursuum to
the Convaanri License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
O lam exempt under Sec. ,B.SP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Dare WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
I hereby allirm that I have a certificate ofconsent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified r s]"l l r A ZONING J ENG.SITE NO.
copy thereof) c 38 l 00,Lab.C. xl,
Policy No Company
O ❑ CeUt d opy is here by urnislteJ. FIRE SPRINK ENERGY FPA
z Z ❑ CeNdia y is fIqw h the city insp-clip, division.
MISC. REFER TO ORD.
Applicant Y ❑ N❑ I Y ❑ N❑
OC LO Cl:RI 119CA'I'E OI IiMvl']ON FROM WORKERS' PERMIT ISSUANCE 10.00 Dc FLOOD ZONE A.L.U.c.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PL -
CL O 1'1'his section need not be completed if the permit is for one T ,OTAL A Y❑ N❑ Y❑ NE]
Z hundred dollars IS I on0or less.)
U O I certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mitis issued, I shall pot employ any person in any manner so as to
0U become subject to the Workers Compensation Laws of California. BUILDING
Q. Ilam Applicant ALTER OR ADD TO MECH. 5.00
} W NO'f ICI:TO APPLICANT: IL utter making this Certificate of Ex-
F Z_ emption,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 shut[be dccmcd 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
I hereby affirm that there is a construction]ending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that l have read thiseppliemipn and slate trial the above VENTILATION FAN (SINGLE) 4.00
• information is correct. I agree to comply with all city and county PLUMBING
ordinances and stale laws relating to building construction. and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,0008TU)SEE FEESCH. MECHANICAL
above mentioned 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 way accrue against said City in consequence of the
granting of r it. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
\/ Signature of. p¢ nt/ ntrac r Uate
/X- INSPECTOR COPY