C9102 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT 1 DENTI FICATI ON PERMIT NUMBER
' ILDINGAPPLICATION & PERMIT
U
BUILDING -'ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S 9102
v ` PLAN CHECK VALIDATION
�rNnuE TY ELECTRIC PERMIT FEE
PHONECONT (/
NAME crOR's OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME
Q CIL.No. LIGHTING FIXTURES 10.00/1.00
ADDRESS
PPLIANCES-RESIDENTIAL 4.00
CONTRAS
• PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.GAN,
OR
ENGINEER
Llc.NO. SIGNS TRANS. 3.00
noon Ess END. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APnucnrvrs MOTORS SEE FEE SCH. !/
ADDRESS (K\
SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a wo1 hereby affirm that 1 am licensed under provisions of Chapter 9 9 ISSUANCE DATE
(connncneing with Sceliun 7000)of Division 3 of the Business anJ t BLDG. ELECT, PLG. MECH.
r �zo Professions Code,and my license is in lull force and effect. I ❑ ❑ ❑
z O v - License Class Lie.Number
o m ea Date-Contractor
¢ mE " _ BUILDING PERMIT
¢ ¢ w < OWNER -BUILDER DECLARATION INFORMATION
w3 LL I- I hereby affirm that I am exempt from the Contractors License MISC.- REFER TO ORD VALUATION S/FT. ,
F u o 4 Law lirr the following reason.(Sec 7031.5,Businessand Professions PERMIT ISSUANCE 10.00
Code:Any city orcounty which reyuiresa permit to construct,alter,
¢ u, ¢ improve,demolish,at repair any structure prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
-o¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
e. w m¢ he is licensed pursuant to the provisions of the Contractor's License
r z i Law(Chapter 9(commencing with Section 7000)o f Division 3 ofthe .y�,q V e�
E E o BuslncsS'and Professions Code)or that he is exempt therefrom and 19
QTY. PLUMBING PERMIT FEE /s O
IS I- a Ole basis for tlm ullegcd exemption.Any violation ofSectim,7031.5 STORIES TYPE CONSTR.
n ; m by any applicant for a permit subjects the applicant ton.civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(5500).)'
❑ 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
Cade:'I'Iw 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.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such it"
prove-
mensare not intended or offered for sale.If.however,the building GAS-EA.SYSTEM-I1NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner-
_ builder will have the burden of proving that he did not build or ire- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
'love In,purpose nl'saleJ. INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ I,as owner of the property,ane exsdusively contracting with ❑ ❑ ❑ ❑ ❑s
licensed contractors to construct the project(Sec. 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
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts forsuch projects with acontractons)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ Ian,cxcie under Sce. .B.&P.C.Ii.r this WATER HEATER W/VENT 6.00
V on 1A
'T Owner ! nate t,1P,, WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO,
WORK ERS'COMPENSATION 1 ECI.ARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate ofconsertt to self-insure, ZONING ENG.SITE NO...
or u certificate of Workers'Compensation Insurance,or a certified
` 'copy thereof(See.3800,L,RC.).
policy No. COmpnGy
Q ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is fled with the city inspection division. MISC- REFER TO ORD.O Applicant Y ❑ N❑ V ❑ N❑
fr m CIi RTI I'I CA'11:01'EXEMPTION PROM WOR K Ii RS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.Lu.C.
LU > COMPENSATION INSURANCI'. PLG.CONTR. LIC.NO. PLG.
d O This action need not be completed if the permit is for one TOTAL Y❑ NE] Y ❑ N❑
D Z hundred dollars IS 100)or I.,)
U O 1 certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I Shall not employ any person in any manner so as to
O become subject to lite Workers'Compensut ion Laws of California.
a Date Applicaet ALTER OR ADD TO MECH. 5.00 BUILDING
} rn NOTICE '1'0 APPIACAN'1': If,after making this Cert if ieate of Ex-
F Z_ eniption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK /
provisions of the Labor Code, you must forthwith comply with FEE
C) 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 10100DC.EM.) 6.00 SEISMIC FEE
1 hereby affirm them there Is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the perl'nrmencc of lite work for which this permit is issued(Sec. MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lander's Address ELECTRIC
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE)' 4.00
information is Carmel. Lugreu to comply with all city and county PLUMBING
ordinances 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 BOILER-COMP (Over IOg0006TU1SEE FEESCH. 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 CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
granting of if is permit / MECH.CONT. LIC.NO. MECH.
/ef TOTAL TOTAL X/O 74
Signature OLA be / ntr for al Dat
INSPECTOR COPY