9277 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LD ING PROJECT I DENTIFICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT ����
aOOREss
1 S rIFSTa W. �1 t BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME TV. ELECTRIC PERMIT FEE
vuorvE
NAME
c NTnacrDR's UTLETS-SW'TC
HES-RECEP 10.00/1.00
LIC.No. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
ARCRITECT PLAN CHECK FEE P.C.NO,
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS Ervc. SPECIAL CIRCUIT. 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 PAID
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 111L
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 J V
¢ 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ®
ya N (commencing with Section 7000)of Division 3 of the Business and 'BL EC PLG. MECH.
F N z Prol'essiuns Code,and Try license is in full force and effect. / El ❑ ❑
z o re License Class Lic.Number
o w- o Date Contractor
¢ Y s BUIL ING PERMIT
¢ ¢
Or c OWNER-BUILDER DECLARATION IN ORMATION
oAU MISC.- REFER TO ORD
w u y 1 herebyil collo that 1 am exempt (ruin the Contractor's s Leense VALUA ION $/FT.
r .. o j Law for Nle following FIly which
(Sec.7133 L5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which aqu tura permit m construct,,also
W , < 0
improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIG N0. ELEC. I
w m u requires the applicant for such pennit to file a signed Statement that TOTAL PERMIT T
he is licensed pursuant to Ote provisions of the Contractor's License
r• z i Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe
< Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
pro the basis for thealleged exemption.Any violation of Scetion7031.5 STORIES TYPE CONSTR.
a ;ro by any rEl licunt for u permit subjects the applicant to u civil penalty
of not more than five hundred dollar, S500L). ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ 1,as owner of Ole property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their SOIL conlpereadio 1,Will d0 the work,and the strnet Ute is not OCC.GROUP RES.UNITS
intended or offered for .IS (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 SO.FT FLDDRAREA TOTAL ACREAGE
martsre of rote his own amred fors,provided ev such illmrovm .
mems are not intended orofferedfor smrovided that r.suhe...prong GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
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 he did not build or int - . - .
- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND C❑ON AS Other
O i
1,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Conimctor s License Law does not apply
m an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractods)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 ACT NO. PARCEL NO.
0 lam exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason _
\X- Owner Uate WATER SYSTEM 5.00
ti ACC.DATE ACG FILE NO.
'OR KERS'COMPIi, ATION DIiCLARAPION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a cerlificate ofconsem to cl Gir,mc. TONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.). '
Policy No. Company
O ❑ Cartiticd copy is hereby furnished. ` FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is Bled with the city inspection division.
O Applicant MISC.- REFER TO ORD. YE] NE] YE] NE]
~ wPERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.c.
CERTIFICATE 01:EXEMPTION FROM WORKERS'
W > COhIPF•NSATION INSURANCE PLO.CONTR. LIC.NO. PLG.
CL Z (This section need mol be co\inpleted if the permit is for one. TOTAL Y N Y N�
h a n d red dollars IS 100)o r less.) A�
U O 1 certify that in the pudaman cc ofthe work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL f- mit is issued,1 shall not employ any persnnliT any manner so as to
U become subject to the Workers CompcnsationlLaws of California. BUILDING
CL Date Applicant Is,
ALTER OR ADD TO MECH. ' 5.00
- } GO NOTIC17 '1 O APPLICANT: If,after making this`- td¢ate of Ex-
F 2 entption,you should become subject to the Workers'GaptpiRmdion APPLIANCE 5.00 'y,• PLAN CHECK
Provisions of the Labor Code, you must forthwith co ply with •
- FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY ssAIR HANDLING UNIT(OVER I0)000C.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 3097,performance
rforC ante of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name HEATI PIG'UN IT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I Certify that I have read this application and state that Nle above VENTILATION FAN (SINGLE) 4.00
information is correct.1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and B01LF.A-COW(3H.P.or100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep hamdess 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 ofthiSrOrmi t MECH.CONT. LIC.NO. MECH.
\ / ✓it / iC Y , L� !7-( / TOT TOTAL
x Sint plicent/Cont a or Date %
INSPECTOR COPY
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