9247 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
PERMIT NUMBER
BUILDING APPLICATION & PERMIT 8247
ADDRESS
111 Alm BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
0 ry 'S - PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
ONE
cni
u.NTRACTURs I
NAME UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.No. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
'
ADDDRESSDRESSPPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10,00 DATE OF APPLICATION
RRCHITECi PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE PNO
.ENGINEER
N .
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRESS ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZnP EMP.METER OR POLE INS. 20.00
APPLICANT'$
ADDRESS MOTORS SEE FEE SCH.
/J
SERVICE CHANGE 20.00
02 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a u v 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
vi Q w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
x, N z Professions code,and my license is in full force and effect ❑ ❑ ❑
o 0 m W License Class Lic.Number
Date Contractor
a Y f '� BUILDING PERMIT
M O re U •A OWNER-BUILDER DECLARATION INFORMATION
E:
g a H I hereby affirm that I am exempt from the Contrnctor's License MISC.- REFER TO ORD
uo� Law for the following reason. 7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
wu, Code'.Any city or,cculty which ruquiresaperm it to construct alter,
oimprove,demolish,nr,mpuir any structure,prior to its issrmnce,also ELEC.CONTR. LIC.No. ELEC.
- o M requires the applicant for such punnet to file i signed statement that TOTAL
d w m I., be is licensed p irsmint to the provisions of the Contractor's License PERMIT TO
Fzi Law(Chaper 9(commcoeing with Section 7000)of Division 3 of they
- a Business and Professions Code)or that ha is exempt therefrom and QTY. PLUMBING PERMIT FEE 12L-G.3 G'
R I o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a ';; � by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars($500).):
O I,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEV ICE 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,CONE). 5.06
Code:The Contractor 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-
mentsare not intended oroffered for sale.If,however,the building GAS-EA.SYSTEM-1 1 NC.4 OUTLETS 6.00
Or improvement is sold within one year of completion, - . -OVER 4 (EA.) 2.00 the owner- GAS EASYSTEM
builder will have the burden of proving that he did not build or inn- BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ L,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
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 contract.oO licensed pursuant to
the Contractor's License Law. SEWER-SAN TARV-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 6.00
mason
Owner Date WATER SYSTEM X90
�C ACC.DATE ACG FILE NO.
WO KI: s COM :N ECLARATION11. yvn WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.). -
Policy No. Cmnpa y
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑. Certified copy is filed with the city inspection division.
MISC- REFER TO ORD.
O Applicant Y N� Y EJ NE]
W CERT'IPICA'rE oP EXEMPTION FROM WORKERS' PERMIT ISSUANCE JA-00 FLOOD ZONE A.L.U.C.
L COhIPE.NSA'601,1 INSURANCE V NY PLG.CONTR. LIC.NO. PLG. W � N�
CL O ('Phis section need not be completed if the permit is for one TOTAL (�
Z) Z hundred dollar,(SI00)or less.)
U 0 L certify that in the perfuromnce of We work I'or which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
L I- mit is issued,I shall not employ any Parson in any tour"'so as to
Ow become subject b the Workers'Compensation Luws ol'Califomia.
C. Oats Applicant BUILDING
>_ m NOTICE TO AI PT[CAN'I': If,after making this Certificate of fix- ALTER OR ADD TO MECH. 5.00
F Z ennption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
jj provisions of the Labor Code, you must forthwith comply with
•such provisions or this penmil shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10)0000F.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 Iilr which this permit is issued(Sec. MICROFILM
3097,Civ.C.). H EATING UN IT(TO 100.000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)Lender's Address ELECTRIC
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree 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
above-mentioned property for inspection purposes. BOILER-COMP IOve.100,000 BTU)SEE FEE SCH. MECHANICAL
(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 I;Hot Said City in consequence of the PERMIT ISSUANCE 10.00
gr Ingo his n L MECH.CONT. LIG NO. MECH.
TOTAL TOTAL
Si [ lis nt c I at
INSPECTOR COPY