9284 (2) 1 01
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT1DENTIFICATION PERMIT NUMBER t
BUILDINGAPPLICATION & PERMIT
9284
T ADDRESS
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
Ow 5 PLAN CHECK VALIDATION
NAM CITY. ELECTRIC PERMIT FEE
4®\
NE
C NTRACTOP'S CTj.
NAME ,.[1 OUTLETS-SWITCHES-RECEP 10.00/1.00 `�L
(V era No
.Q LIGHTING FIXTURES 15,00/1.00C/b `
CONT A TORS PPLIANCES-RESIDENTIAL 4.00
ADDRESS
HON fbk PANELS 10-00 DATE OF APPLICATION
ARCHT PLAN CHECK FEE P.C.NO.
on PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.No. SIGNS TRANS. 3.00 '
ADDRESS ENc. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
rZIP EMP.METER OR POLE INS. 20.00
T
APPLICANS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a v U I hereby affirm that I am licensed ander provisions of Chapter 9 ! ISSUANCE DATE
way (commrncing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F D z Professions Code and m icense is in full force and effect ❑ ❑ ❑ ❑
ez 0 m-- License Cl:us_1 / Lie.Number
�0 m H Dale Contructor-
a r E J BUILDING PERMIT
m'M M ¢ N ILUF.R DF CLA AFION
0 u INFORMATION
Lo ; Is I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
- LLL o 4 Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE VALUATION S/FT.
Code Any city or county which requires a permit to construct,utter, _
improve,demolish,or repair any structure,prior to its issuance.also ELEC.CONTR. LIC.NO.
"¢ 4 0 I P p' Y ELEG.
0 IC requires the applicant for such permit to file signed statement that TOTAL PERMIT TO
M1' w w he is licensed pursuant to the provisions of the Contractor's License -'
Fz >
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
4 Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
Ce
r o the basis for the alleged exemption.Any violation of Section 7031.5 RI E CONSTR.
a ;m by any applicant for a permit subjects the applicant too civil penally ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(55001.):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC,GROUP RES.UNITS
isk their sole compensation,will do the work,and the structure Is not
intended or offered far 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
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 improve-
mems are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or int 1,as o RES IND CON PB Other
prove of sale.). . 30.00 0 ❑ ❑ 0 ❑
❑ 1,as ownernee of the property,am exclusively contracting with INDUSTRIAL WASTE INTER
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 for such projects with a contractor(s)licensed pursuant to
Q he Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO, PARCEL NO.
❑ I um exempt under SCC.-,B,&P.C.for this WATER HEATER W/VENT 6.00
,\ reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WURKIiRS'f,OMPIiNSAT10N DECLARATION WATER TREATING EQUIP. 5.00
ti
I hereby.]firm that have a ce Compensc.cation
I consent or set ensue d - ZONING ENG.SITE NO.
or a certificate(See
Workers'Compensation Insurance,or a certified
- Policy No of lSec.3800 Lab-CL
Policy No gyp)
W Q ❑ Cc ifie cpy is"M1 c turn the FIRE SPRINK ENERGY T-24
Z Z �.Certified copy is bled with the city inspe ton divisionebece.
MISC.- REFER TO ORO.
- O n1(pliuuv v � N� v [:] NE]
CC W CERTIFICATE 017 EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 LFLOODZONE A.L.U.C.
n; W :t' COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
Z f1'his section end not be completed it the permit is for one TOTAL Y❑ NE] Y F] N❑
hundred dollars IS 100)or less.)
V O 1 certify that in the performance of the work for which this per- FEE SUMMARY
LL 1- mit is issued, 1 shall not employ any person in any manner so as to OTY. MECHANICAL PERMIT FEE
--T 0 0 become ubjeel to the Worker Compcnsutiun Laws.1 Culifomia. BUILDING
o, Dam Applicant - ALTER OR ADD TO MECH. 5.00
} m NOTICE '1'0 APPLICANT: If,after making this Certificate of Fs-
F 2 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
CJ such provisions or this permit shat)be deemed revoked. AIR HANDLING UNIT(TO 10DWC.F.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10)M0C.F.M.) 6.00 SEISMIC FEE
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.Civ.CJL HEATING UNIT(TO 100,000 B.T.U.) 8.00
,. Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's aAresS ELECTRIC
1 certify that I have read this uppficatinn and state that the above VENTILATION FAN (SINGLE) 4.00
infonnalion is correct. I agree to comply with all city and county PLUMBING
f' ordinances and state laws relating m building construction, and BOILER-COMP(3 H.P.or 100,000B.T.U.) 6.00
- hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
abovomentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino again liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in
all Fy accrue against said City in consequena, of the
granting of t permit. MECH.MECH.CONT. LIC.NO. MECH.
!/ TOTAL TOTAL
n r
Sige of Applic C tactor Dat
INSPECTOR COPY