9104 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING
APPLICATION & PERMIT
ADDRESS �� O�
UESS
IL
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
coN7RAcroRa 3�'�907 T UTLETS-SWITCHES-RECEP 10.00/1.00
ME
uc LIGHTING FIXTURES 10.00/1.00
DREss
Ac .s PPLIANCES-RESIDENTIAL 4.00 El
a
PHONE PANELS 10.00 DATE OF APPLICATION
ORRCHITE PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.N0.
ENGINEER
�- LIC.No. SIGNS TRANS. 3.00
AARCH.OR DDRESS ENG SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
L
P TEMP.METER OR POLE INS. 20.00
APDRCESS $
ADDRESS MOTORS SEE FEE SCH. 7/
O f
SERVICE CHANGE 20.00
ao o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
mi n I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE GATE
4 (commencing with Section 7000)of Division 3 of the Business and BLD ELECT. PLG. MECH.
F m i P ofCssions Co e,m)d my licm is.is in full force m ffec
z o w - License Class -O(//��Lic.Number-/-�s�� _ ❑ El El
o F Dam.(�ca. ___p_�Contractor- , �
4 Y E , (// �� BUILDING PERMIT
o n U OWNER-BUILDER DECLARATION INFORMATION
w3 U. 1 1 hereby affirm first I am exempt from the Contractor's License MISC.- REFER TO ORD
VALUATION `I $/FT.
FUO4 Law for the following reason,(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 O"
3 w e, Code:Any city or county which recuiresa permit to construct,alter. ELEC.CONTE. Lt C.NO. V 1
ar 4 p improve,demolish,or repair any structure,prior to its issuance.also ELEG.
u
A m u requires the applicant for such permit to file a signed statement that TOTAL ERMIT T
w he is licensed pursuant to the provisions of the Contractor's License
zi
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
4 Business and Professions Code)or that he is exempt therefrom and OTY.w PLUMBING PERMIT FEE
E x o
x rathe basisfpr insulter exertprion.Any violationt to acliun malty STORMS' PE CONSTR.
or '.2 by any.(net applicant fora rmcl,rsubjecr, 500).licanttnacivil penalty ALTER-DRAIN St VENT-WATER.(net mom Ihun five hundred dollars(5500)J:
❑ 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
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5,00 SO.FT.FLOOR AREA TOTALACREAGE
himself or through his own CmP1oyCCs,provided that such improve. .
mems are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving that tic did not build or inn. BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 RES .IND Pe Omer
❑ 1,as owner of the property,am . . Co exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 AE61ESSUH5 PkKULL NO.
and Professions Code:'I he Contractor's License Law docs 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.
❑ l am exempt under Sec. ,BAP.C.tion this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPEN'SA'rION DECLARATION WATER TREATING EQUIP. 5.00_ '
I hereby affirm that I have a certificate of ronownt to sell-insure, .+1' ZONING ENG.SITE NO.
or a certificate of Workers'Compensation I surancC,or a cenifieJ
' copy therco lScc.3 0,Lah.0-). J
Policy No p�yj� ,
0 ❑ Cenrm c, hf)f(r d' FIRE SPRINK ENERGY T 24
Z Z ❑ Cerlifcopy'ied Ia with city inspection divisio
/�c /_ w _ MISC.- REFER TO ORD.
O Applicant Y ❑ N❑ i v ❑ N❑
fY to CIS RTI I% A'LEOE EXI?MPTION f ROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
L �_ CON _N•SA'PIONINSURIW CF: PLG.CONTE. LIC NO. PLG. -
d O 1'I his section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
Z hundred dollars IS 100)or le.I
V O I certify that in the performmrice of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
U_ F mit is issued,I shall nor employ any person ho any numncr s,,as to
O W become subject to the Workers' ns
Compeation Laws of California
py\
Date Applicam ALTER OR ADD TO MECH. 5.00 BUILDING
C. O
J
} to NO'I ICE TO APPLICANT: IL at oinking this Certificate of E;x-
F ? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK /-j
provisions of the Labor Code, you must forthwith comply with FEE 6
U " such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000Q F.M.) 4.00
CONSTRUC'T'ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I 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.CiveC). HEATING UNIT(TO 100,000 B.T.U.) 8.00 . .-
Lender's Nddr HEATING UNIT(OVER 100,000 B.T:U.)9.50
Lender's Names ELECTRIC
I certify that 1 have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00
inforn Ition is correct. I agree to comply with all city and county PLUMBING
o-dinan«s and state 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
abnvC-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCM. MECHANICAL
(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 this permit. MECH.CONT. LIC.NO. - MECH.
TOTAL TOTAL (p�
Signature of A pplican t/Contractor Date
INSPECTOR COPY