8493 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDING PROJECT I DENTI FI CATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
�DgES , f BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 8493
OWME / PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
PHONE
CdNTWCIrOR UTLETS-SWITCHES-RECEP 10.00/1.00
! NAME r
UC.o. ax LIGHTING FIXTURES 10.00/1.00
r.TN7453^ S I V PPLIANCES-RESIDENTIAL 4.00
YPH G PANELS 10.00 DATE OF APPLICATION
ADDRE• q IT T PANELS (OVER 200 AMPI 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
noun.,Ess EN¢ SPECIAL CIRCUIT 5.00 PERMIT VALIDATION -
' ZIP EMP.METER OR POLE INS. 20.00
ADDDRESSDRESS
Ars MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
F'o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
Q U v I hereby affirm that I am licensed under previsions of Chapter 9 ISSUANCE DATE
I
z y (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F w z I'mfessions Code,and m 'cense rs in full forte and clfec. ❑ 1:1 _ ❑
'e o m - License Class a Lit.Number (_
o r 'pal¢ Contractor
¢ yEN U d,I BUILDING .MIT
Ix Q w O R-BUILOF:R. C1Q AI INFORMATION
6 o.A MISC.- REFER TO ORD
w 3 LL I hereby af)irm that I am exempt from circ Contras is Licens VALUATION $/FT.
� u0J Law for the following reason.(Sec.7031.5,Businessand PTWCSSInnS PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTH. LIC.NO. ELEC.
¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
wu he is licensed pursuant to the provisions of the Contractor's License
r z i
Law(Chapter 9(10m mencingwith Section 7000)o f Division Sal'the
< Business and 1 rofussions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
r o the basis for lire alleged exemption.Any violation of Section 7031.5 STORIES T PE CONSTR.
o -; c' by any applicant for a permit subjects the applicant too civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than live hundred dollars($500)J,
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 occ.GROUP RES,UNITS
then sole compensalion,will do the work,and lire structure is not
intended or offered for 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 docs such work FIXTURES-PER TRAP 5.00 SG.FT.FLOOR AREA TOTAL ACREAGE,
himself or through his own employees,provided that such improve-
mentsareOut intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 6.00 j
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 ire- RES IND CON PB Deer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
11I,as owner of the Property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to .mo att the project(Sec. 7044,Husiness 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 properly who builds or improves thereon,and who LAWN SPRINKLERS-OV ER 5(EA.) 1.00
contracts for such projects with a conlmct.alo licensed pursuant to SEWER-SANITARY-STORM EA.200ht/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ 1 am exempt under Seo.-,B.&P.C.for this WATER HEATER W/VENT 6.00
seri"!!
Owner Dale WATER SYSTEM 5.00 ACC.DATE ACC.FILENO.
s / WORKERS'COMPENSATION UCCLARA'nON WATER TREATING EQUIP. 5.00
II heroby,trim tbnt I have a certificate of atconsent to reGinsure' ZONING
or a certifice of Worker,Compensation Insurance,or u cert ificd ENG.SITE N0.
copy themo((See 3800,Lab CA
1policy No, Company
I ❑ CcrtificA amy is hereby furnished.
FIRE SPRINK ENERGY TTA
z ❑ Cartil'icd copy is fled with the tits' inspection division.
0
p- Applicant MISC.- REFER TO ORD. y ❑ N❑ y ❑ No
r rn PERMIT ISSUANCE 10 FLOOD ZONE A.L.U.c.
� CIiRTIFICA'lli E EXEMPTION ION ION PROh1 WORK ERS'
W COh1Potbe oni INSURANCE PLO.CONT.. LIC.NO. PLG. y❑ N❑ Y❑ N❑
Z) Z hundred
declare need not be completed if the permit IS for one TOTAL
hundred Jallars(5100)or less.) '
U 0 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
lL H mil is issued,I shall not employ any person in any manner so as to
OW hecom sublet eW'orkers'Compenzafion awso Ca'ornia.
Q_ Dat�� OAPvlicam -i. 4� ALTER OR ADD TO MECH. 5.00 BUILDING
} to NO' I li 1 LICAN"f: I .•a l n ak n this'C rtfrl ¢
F 2 emption,you should become subject to the Worklrs'Competh ation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
CJ 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 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm fiat there is a construction Reding agency nor EXHAUST HOOD (WITH DUCT) 5.00
the periannance of the work]or which this permit is issued(Svc. MICROFILM
3097,Civ.C,), HEATING UNIT(TO 100,000 B.T.U.) 8.00
Leaders Name
Lenders Address HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
infontalion 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 BOILER-COMP tosser 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly 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
grant! oft is per, �. MECH.CONT. LIC.NO. MECH.
' d /J.f' _ TOTAL TOTAL
/1\/1 Si u o Appli n' tr c r tl rl wfisf
INSPECTOR COPY
I