8291 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT 1 DENTI FICATI ON PERMIT NUMBER
BOA-DING APPLICATION & PERMIT ����
ADDRESS
Q IV BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
m
'S PLAN CHECK VALIDATION
"AME OTV. ELECTRIC PERMIT FEE jj / [S•
_ I PRONE �d 1 _y
Cf/
ONTRACTOR'S C
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00 �! („ }
- r LIGHTING FIXTURES 10.00/1.00
sec.No.
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADDRESS �1/(�
PANELS 10.00 DATE K APPLICATION
TELT PANELS (OVER 200 AMP) 2000 PLAN CHECK FEE P.C.NO.
OR
r ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
991N� Y r 4 P• ZIP EMP.METER OR POLE INS. 20.00
ADDRESSS PAIS
APPLIDAMOTORS SEE FEE SCH.
ca SERVICE CHANGE 20.00 JUN /� I��
SE o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 p�s' �Q Q .{
a wo I hereby affirm That I am licensed under provisions of Chapter 9 y�yJq tE$��EP'11Ino
y a w (commencing with Section 7000)of Division 3 of The Business and BL ELECT. PLG. MECH.
H y 0 Professions Cod,,and my license is in full burre and effect.
a; o m - License Class_ Lic.Number dJ�'
9 H 0 Date Contractor'.)- ,r
¢ y� _J BUILDING PERMIT
¢ ¢ w a OWNER-BUILDER IN CLARATION
o INFORMATION
K 3: MISC.- REFER TO ORD
w 3 LL N I hereby affirm that 1 am exempt from the Contractor's License VALUATION SIFT.
F LL
Cat Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit To construct,alter,
2 2 ¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
O LL requires the applicant for such permit to file a signed statmnent That TOTAL PERMITTO
a w m w he is licensed pursuant to the provisions of the Contractors License
F z a Law(Chapter9(commenciagwith Section 7000001Division3ofthe
a Business and Professions Code)or That he is exempt therefrom and QTV. PLUMBING PERMIT FEE
F i o
¢ t- The basis for the alleged exemption.Any violation of Section 7031,5 5 R E TYPE CONSTR.
d3� by any applicant for a permit subjects The applicant To a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of nal more than five hundred dollars(5500).1:
❑ 1,.s owner of The property,or my employees with wages as BACK F LOW PROTECT. DEV ICE 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,AR EA,GOND. 5.00 '
Code:'[he Contractor's License Law does not apply to an owner of -
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 T.FT,FLOOR AREA TOTAL ACREAGE
• himself re through his own em Players.provided that such improve-
mentsarenotingended hhiso coffered for sale.If, that Sthe...pro building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, - . -OVER 4 (EA.) 2.00 the owner. GAS EASYSTEM
builder will have the burden of Prawn.that he did not build or inn- BUILDING SE
prove for purpose of sale.). INDUSTRIALWASTE INTER. 30.00 RES IND C PB Omer
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors RI construct the project(Sea 7044, Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSOR PARCEL NO.
and Professions Code:The 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 ract as License
ts Lwithacomructorls)licensed Pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO.r PARCEL NO.
The Contractor's License Lew.
❑ IomrxcmpTtmdcr Sec. _ .B.&P.CRx this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
„WORKERS'COMPEN'SA'FION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure.
or a"atifi,me of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.,
copy thereof(Sec.3800,Lab.C.).
Policy No. Company'
O ❑ Cc,NfirdcopyisherebyrT-ls a FIRESPRINK ENERGY T 24
Z Z O Cerli;; copy is Bled itti The city inspection'division.
0 Applicant�yd._F�.€r MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ NQ
CC = CERTIFICATEOfz EXEMPTION ROM1I WO :RS• PERMIT ISSUANCE 10.00 FLOOD ZONE AL.UC.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
Q.Q. Z ('P his,section need not be completed if the permit is for one TOTAL Y❑ N❑ Y E] NE]
hundred doll...(S 100)or Irss.)
U % 1 certify tlusfm the.performance of The work nio
x which This per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL f- mit is issued, I shall not employ any person in any manner so as to
U become subject to The Workers Compensation Laws of California.
U u Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} w' NOTICE TO APPLICANT: If,after umking 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 shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I Tricky 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,Ce,.C.). HEATING UNIT(TO 100,000 B.T.U.)' 8.00
Lender's Nome HEATING UNIT(OVER 100,000 B.T.U.)9.50
LenderS Namess •L ELECTRIC
I certify chat 1 have read this application and stat,That the above VENTILATION FAN (SINGLE) 4.00
intornmtion is correct. I agree to comply with all city and county .PLUMBING
ordinances and state laws relating to building construction. and BOILER-COMP(3H.R or100,000B.T.U.) 6.00
hereby authorize representatives of this city 10 cuter upon Ihr BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
u6ove-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 CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
grunting o(Ihis penniT, MECH.CONT. LIC NO. MECH,
AL 116T, oTAL TOTAL
Ign 6fi A-pc t on Vector ) e
INSPECTOR CO-
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