9172 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY A
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
RuitoirvG APPLICATION & PERMIT i ��
AUILDIss
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL !
W H'5 PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
PHONE
NANME Acr UTLETS-SWITCHES-RECEP 10.00/1.00
Lic.No. LIGHTING FIXTURES 10.00/1.00
ANTRA9TOH'
AUURESS APPLIANCES-RESIDENTIAL 4.00
PHOrvE PANELS 10.00 DATE OF APPLICATION
CATION
PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
UC.NO. SIGNS TRANS. 3.00
A GORESS cmc. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
zlP TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
o o LICENSEDCONTRAallu
DCCLARATIpN TEMP.POLE 30.00 //��
u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
ti G (commencing with Sfflion 7000)of Division 3 of the B.Mness and BLDG. ELECT. PLG. MECH.
F w z Professions Code,and m license is in full force and effect 1 ❑ ❑ ❑•+
z o w- - License Class Lic.Number_ 474 5.?_7 I
0 w r Dmc Contmcto ,/
Y E BUILDING PERMIT
w u OWNER-BUILDER DECLARATION INFORMATION
w; LL N `. .l hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION S/FT.
F u
04 Law far the following reason.(Sec.7031.5,Business and 1'rolessions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
rc ¢ o improve,demolish,or repair any structure,prior 10 its issuance,also ELEC.CONTE. LIC:N0. ELEC.
0 , requires the applicant for such permit to file a signed statement that
TOTAL PERMIT TO
a w es he is licensed pursuant to the provisions of the Contractors License
Hz
Law(Chapter 9(Commencing with Section 7000)of Division 3 ofte L�'
Iiness and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
f ¢o the iusbasis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
nam by any applicant l'or a permit subjects the applicant Ica civil penalty ALTER-DRAIN -WATER (EA.) 5.00
Of mol more than five hundred dollars($500)J'.
❑ 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 tire work,and the structure is not
intended or offered for sale (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Cade:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work 0 FIXTURES-PER TRAP f00 50.FT.FLOOR AREA TOTALACREAGE
• himself or through his own employees,provided that such improve- if
mein,are net intended or offered for sale.If,however,lire building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00 It
or improvement is sold within one year of completion,the owner- GAS EASYSTEM-OVER 4 IEA) 200
builder will have the burden of proving that h - .e did not build or im- . . BUILDING USE
Prove for purpose of sale.). INDUSTRIAL WASTE INTER30.00 RE5 IND CON PB Omer
❑ I,as owner of the property,mn exclusively contracting w .ish ❑ ❑ ❑ ❑ ❑
licensed contractors to construcolhe project(See. 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
In in owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts mr such projects with a contractorts)licensed pursuant no SEWER-SANITARY-STORM EA200f 1000
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ Iumexemptunder Sec. ,B.&P.C.for Ibis . .
WATER HEATER W/VENT 6.00
letutill
Owner Date WATER SYSTEM 560 ACC.DATE ACC.FILE NO.
WORK ERs'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate ofconscut to self-insure, ZONING or a certificate of Workers'Compensation Insurance,ora certified ENG.SITE NO.
alpy thereot(See.3800,Lab.C.I
Rol icy N���'/�.L�.jF.[y�.onlpany �S --�+7� ) _
0 O Ceiti eel dcopy is hereby' lines lf�-P�cita¢��rTI IFIRE SPRINK ENERGY L]4
' x Z 2 Q- Certified Copy is filed I� city inspecti 1 JivOmm MISC.- REFER TO ORD.
Q 7lppllcant• //U Y ❑ N❑ V ❑ N❑
` cc CERTIFICATE Ob-ESEb1RrioN 17ROMW'O K IiRS. PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.C.
LU 5 COMPENSATION INSURANCE P .CONTR. LIC.NO. PLG.
Z (This section need nm be completed if the permit is for one OTAL V❑ N❑ Y ❑ N❑
hundred dollars(S 100)or IessJ
V O 1 certify that in the performance Of the work nix which it,,,per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any manner so as m
O w become subject to the Workers'Compensation Laws of California.
y D:nc Applicant ) ALTER OR ADD TO MECH. 5.00 BUILDING
} m NOTICE '10 APPLICANT': If,after making this Certifieulf of Es-
r 2 emption,you should become subject to tire Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of rhe ISabor Code, you mustrforthwilh comply with FEE
U such provisions or this'pernlit shall be deemed revoked. AIR HANDLING UNIT(TO I0=C.F.M.) 4.00
Y` I AIR HANDLING UNIT 10
j CONSTR UCfION LL:NDI NG�AGENCY /j ,000GF.M.1 6.00 SEISMIC FEE
hereby affirm that thcre.ls a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the Perlorml of the work for which this permit is issued(Secs MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name �� - 7•'
1.CRdcr's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
it11
I certify that I have mud phis 1)Coapplication and stute,ty at the above VENTILATION FAN (SINGLE) 4.00
ordinances n correct. I agree m comply with all City and county PLUMBING
ordinance, and stole lows relating to building cons0uction, and BOILER-COMP(3 H.P.or 100,0006.T_U.) 6.00
hereby authorize representatives of this city to en ne upon the BOILER-COMP(Over 100.000 BTU)SEE FEE BCH. 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 thispermit - MECH.CONT. LIC.NQ MECH.
TOTAL TOTAL
rest] p nmf Contruck r al
INSPECTOR COPY