9445 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LOI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDINGOORE - APPLICATION & PERMIT 9445
�( Ass
J
/ BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
, O ER' n PLAN CHECK VALIDATION
N ME
2 - a-GTY- ELECTRIC PERMIT FEE
ONE
�• NAMTRACTORs UTLETS-SWITCHES-RECEP 10.00/1.00
LIC,NO, LIGHTING FIXTURES 10.00/1.00
CONTRACTOR
ADDRESSDRESS APPLIANCES-RESIDENTIAL 4.00
A
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
on PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
moo Ess ENc. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 p r
w O o LICENSED CO\TRACTORS DECLARATION
TEMP.POLE 30.00 6/p/�f
a o U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
vHi "' (commencing with Section 7000)of Division 3 of tiro Business and
¢ y BLDG. ELECT. PLG. MECH.
H w z Professions Code,and my license is in full force and effect ❑ ❑ ❑
iw License Class Loc.Numhcr
w r Llme Contractor
a Y f I BUILDING PERMIT
¢ ¢ 4 OWNER-BUILDER DECLARATION
' Oa" MISC.- REFER TO ORD INFORMATION
w g LL n I hereby affirm that I am exempt from the Contractor's License
I. 0 4 Law for the following reason.(Sec.7031,5.Businessand Professions PERMIT ISSUANCE 10.00 VALUATION 5/FT.
� - w Code:Any city orcounty which requires a permit o construct,alter,
KK ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
F D ¢ requires the apjllicant for such permit to file a signed statement that TDTAL
A w m he is licensed pursuant to the provisions of the Contactors License PERMIT TO
Hzi Law(Chapter 9(commencing with Seclion 7000)of Division 3 of01e B�
4 Business and Professions Code)or that he is exempt therefrom and GTY. PLUMBING PERMIT FEE IDL
r ¢'r o the basis for the alleged exemption,An
gc p Any violation of$ection 703 L$ STORIES TYPE CONSTR.
r dam by any applicant fur a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(5500).):
❑ 1,as ownerof the property.or my employees with wages as BACK F LOW PROTECT. DEV ICE 4.00
their sole compensation,will do the work,and the structure is not OCCGROUPRES.UNITS
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,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 imp
mrove-
entsarenotintendedorofferedforsale.If.however,the building GAS-EA.SYSTEM-11NC.40UTLETS 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 - . - . .
roving that he did not build or or- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
Cl 1,as owner of the property,and exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044, Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 - ASSESSORS PARCEL N0.
and Pro@ssions Code:"I'he Contramur's Liccnsc Law docs not apply -'
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200tt/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,134P.C.for this
WATER HEATER W/VENT 6.00
reason
Owner DateWATER SYSTEM 5.00 ACC.DATE ACC.FILE N0.
WORKERS'COMPENSA'I'ION DECLARATION WATER TREATING EQUIP. 5.00 xjL
I hereby of firm that I have a certificate of consent to wilcinsure,
Or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG-SITE NO.
copy thereof(See.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished.
FIRE SPRINK ENERGY T74
_Z Z ❑ Certified copy is tiled with the city inspection Division. MISC.- REFER TO ORD.
O Applicant v NE] YE] N�
~ w PERMIT ISSUANCE 10.00 ^.
LU CE RTII4CATIi ENSAiMPfION PROM WORKIiftS' ' _d� FLOOD ZONE A.L.u.c.
W COMPENSATION INSURANCE PLG.CONTR. LIC.NO.Z PLG. / V • Y N❑ Y � ❑(This section need mol be completed if the permit is for one TOTAL N
hundred dollars IS 1the pe form
U O I certify that h l n performance pee work for which this per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued, I shall not employ any person on any manner so ia to
O w became subject to the Workers'Compensation Laws of California.
Date-Applicant Date A
a pp ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE 1'0.AI'1'LIG\N'r: If,after making this Certificate of lix-
Z emption,you should becomesuhjest to the Worker,''Compensmion APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith mR IY with FEE
U such provisions or this permit shall bm
e deemed revoked.. AIR HANDLING UNIT(TO 10=C.F.NL) 4.00
CONS'rRUCf10N LIiNDING AGENCY AIR HANDLING UNIT ROVER 10=C.EM.) 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,Cie.C.), 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 Address ELECTRIC
I certify thin I have read this application and scute that the above VENTILATION FAN (SINGLE) 4.00
® information is correct. I agree to comply'with all city and c.Only
PLUMBING 6PL
ordinances and state laws relating to building construction, anJ BOILER-OOMPI3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives ins inspection
this city tc corer upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purpous.
(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 ascrue against said City in consequence of the
gamin of this ralil. ���� MECH.CONT. LIC.NO. MECH.
/ TOTAL TOTAL
Signature of-A pplaant on tractor Dae w
INSPECTOR COPY
I