9422 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BouLOING APPLICATION & PERMIT g422
ADDRESS
UILDING - ELECTRICAL-PLUMBING-MECHANICAL
0 N PLAN CHECK VALIDATION
NAME TY ELECTRIC PERMIT FEE
PHfs/ -�9
NAMERAcrons K UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO, LIGHTING FIXTURES 10.00/1.00
ADDRESS DRESS ons APPLIANCES-RESIDENTIAL 4.00
PHONE ';Z PANELS 10.00 DATE OF APPLICATION
RRORITEcr PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.rvo. SIGNS TRANS. 3.00
ARCH,OR ADDRESS ENG. \ SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
t ZIP rrEMP.METER OR POLE INS. 20.00 I
AMOTORS SEE FEE SCH.
ADDDRESSDRESS
SERVICE CHANGE 20.00
D¢ z TEMP.POLE 30.00
r O o LICHNSED CONTRACTORS DECLARATION
a u U I hereby affirm Dim I am licensed under provisions of Chapter 9 ISSUANCE DATE
w frronunenuing with Section 7000)oi'Division 3 of[he Business and
ti Q BLDG. ELECT. PLG. MECH.
D z Professions Code,and my license is in full I'o¢e and effect. ♦.'».n- ❑ ❑ ❑ ❑
Z 0 o - License Class ia Number
o z r w Dole J' \ Cm[tructor
a x J BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DECLARATION
o a, U INFORMATION
w ; u H I hereby affirm that I am exempt from tie Contractor's License MISC.- REFER TO ORD
LL 0 sf Law for the following reason.(Sec.7031.5,Business and Professions VALUATION $/FT.
_ PERMIT ISSUANCE 10.00
Code:Any city or county repir my requirure permit to construct.alter,
also .2
y
T . < 0
improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
,. - 0 u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
K
m he is licensed pursuant to the provisions of the Contractor's License
irza
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE /CN 7 17"' G
¢ H o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
dgE
by any applicant for a permit Subjects the applicant toa civil penalty ALTER-DRAIN& VENT-WATER (EA.).5.00
of not more than five hundred dollars C5500L):
❑ 1,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 FIXTURES-PER TRAP 5.00 'S0.FT.FLOOR AREA TOTAL ACREAGE
• himself m through his own employees,provided that such improve-
or nts improvemenotnt
it is Sold or within
onefor
year
e.o lhowever,the The owner-
GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or improvement Ia sold within ane year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
provebuilder will have the burden of proving that he did not build or im- BUILDING USE
for RES IND CON PB OtM1ar
prove 1,asO nee of sale.). INDUSTRIAL WASTE INTER. 30.00 El ❑ ❑ ❑ 11
❑ I,as owner of the property,nm 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"fhe 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 for such projects with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ tum exempn See. .B.&P.C.for this WATER HEATER W/VENT 6.00 `
reason
Owner WATER SYSTEM 5.00 ACC.DATE ACC,FILE NO.
WORKER COMI'ISNSA'DON DI: LARA"PION WATER TREATING EQUIP. 5.00
1 hereby alfirm that I have a certificate of'consmit to elf-mum.
or it cerlifade al Workers'Connontution Insurance,or a certified ZONING ENG.SITE NO.
Copy lhereof(Sec.3800,Lah.CJ.
Policy No. Company
O ❑ CertiOedc'opyishercbyfuntished' FIRE SPRINK ENERGY T-24
Z Z O Certified copy N fled with the city inspection division.
O Applicant MISC.- REFER TO ORD. YE] IN Y ❑ N[:)
PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.D
CER TI PICA]'E OF I:XI'MPTION'FROM WORKERS' .G.
W > COMPENSA'T'ION INSURANCE PLG.CONTR. LIC.NO. PLGCL .
Z( This Section need not be completed if the permit is for one TOTAL Y❑ NE] Y NF]
hundred dollars($100)or less.)
U O I certify flim in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I Strait not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
U i Dare Applicant ALTER OR ADD TO MECH. 5.00 'BUILDING
} to NOTICIi TO APPLICA NI': IC alter making this Ce Ui(icatc of Ex-
f- ? 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 shall be deemed revoked. AIR HANDLING UNIT ITO 10=C.F.lM 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE f'(j
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the permemance of the work for which this permit is issued(Sec. MICROFILM
3097,CIv.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's NamAddress
HEATING UNIT(OVER 100,000 B.T.U.)Lender's nddr<sz ELECTRIC' vU_
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• information is eStan, l I agree to comply with all city and county BOILER-COMP 13 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
oNlnmatio .,,it stole laws relating to building l city construction,co and
hereby authorize representatives of this city to enter upon the
above-nienlioned properly for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(Wa) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgmems, costs and expenuv which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way m;con, against said City in consequence of the
granting of 11 -nni MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL /6"K
Sip r nt/CD tr o e
INSPECTOR COPY
1