8689 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT 1 DENTI FICATI ON PERMIT NUMBER
AWLmSc APPLICATION & PERMIT �^�^
a00REE5 b y
BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
0
/ OTY. ELECTRIC PERMIT FEE PLAry CHECK vnuonnON
® ONE
CONTNAMERa To sS UTLETS-SWITCHES-RECEP 1000/1.00
t LIC.No, LIGHTING FIXTURES 1000/1.00 _
ADDRESSTORS PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ORCHITEGT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
uc.No. SIGNS TRANS. 3.00
ARCHESS R ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS. 20.00
APPLICANTS
ADDRE LICA MOTORS SEE FEE SCH.
SERVICE!CHANGE20.00 /gyp
,00 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 ��Q/"
a u I hereby affirm that I am licensed under Provisions of Chapter 9 ISSUANCE DATE
O1 (conunencmg with Section 7000)of Division 3 of the Business and
BLDG. ELECT. PLG. MECH.
F N.i Professions Code,and my license is in full force and of fuel. ❑ ❑ ❑
o z w a License Class Lie.Number
m r Dale Contractor
C It 4OWNER-BUILDER DECLARATION I BUILDING PERMIT
X ; u m I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD INFORMATION
.
FLLOJ Law for the following reason,(Sec.7031.5Business and Professions PERMIT ISSUANCE VALUATION g/FT.
Code.Anycityorcounly whichrequiresapermitaoe..... halteq .. 10.00
ttrt ¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEG.CONTR. Qj LIC.NO. ELEC.
o Ix requires the applicant for such permit to file a signed statement that YY TOTAL /6 PERMIT TO
a w m w he is licensed pursuant to the provisions of the Contractor's License
Laza Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
x D Business unit Professions Code)or that he is exempt therefrom and ELK'
r a the basis for the alleged ex em pt inn.Any violation al Section 703 LDTV. PLUMBING PERMIT FEE S STORIES TYPE CONSTR.
or
A ,. by any applicant for a permit subjects the applicant toa civil penalty
of not more than five hundred dollars(S500).): _ ALTER-DRAIN& VENT-WATER (EA.) 5.00
❑ 1,as owner of the property,or my eo.ployees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the s rueture Is not
intended or offered for sale (See 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,CON D- 5.00
Code:The Contractors License Law docs not apply to an owner of
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 50.FT.PLIwfl AREA TOTAL ACREAGE
himselforthroughhis own employees,provided thatsmhimprove-.
or improv not is sold or within
on year
sale.If,howetion tire building GAS-EA.SYSTEM-11NC.4 OUTLETS 6.00
or improvement will have
is sold within one year of clic didtion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the harden of proving that he did not build or ire- BUILDING USE
pruvefor purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
lice sC, RES IND CON Pe Omer
Qn/I,us owner of the property;um exclusively Contracting with 11 E] 0 E] El
contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:1'he Contractor's License Law docs not apply
to an owner of properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed Pursuant m
I he Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under Sea ,B.&P.C.(Or this WATER HEATER W/VENT 6.00
reason
�. Owner Fate WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO,
WORKERSCOh1PIiN$ ION DIiCLnIznT10� WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofconsent to'elf-ii...in'.
or a certificate of Workers'Compensation Insurance,or a Certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.). r
Policy No. Company /
O ❑ CeRrImd copy is hereby furnished. FIRE SPRINK ENERGY T24
Z Z ❑ Certified copy is filed with the City inspection division. MISC.- REFER TO ORD.
F O Applicant Yo No YC] No
N CE RTI FICA'If:OF FXFM PTION PROM WORK 1:RS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.o.
LU COMPILWSA'fIONINSURANCE PLG.CONTR. LIC.NO. PLG
0- a( This section need not be completed if the permit is for one TOTAL Y N� Y E] NE]
U O hundred dollar,IS 100)or less.)
I certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued, I shall nut employ any person in any mm�ner so us m
become subject to the Workers'Compensation Laws of California.
O w
y Date-Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE'TO APPLICANT: IL after making this Certificate of lis-
f.. Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with U FEE such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 1Q,000CF.M.) 4.00
CONS'fRUCT10N LENDING AGENCY AIR HANDLING UNIT(OVER I0=C.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.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT 100,000 B.T.U.)9.50
Lenders Address ELECTRIC IO
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
•
it is correct.I agree to comply with all city and County PLUMBING
ordinances and state laws relating to building coenter unstruction, and BOILER-CO (3H.P.or100,0008.T.U.) 6.00
hereby authorize representatives of this city to pon the MPBOILER-COMP (Over 100,000 BTU)SEE FEE SCH. 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 PERMIT ISSUANCE 10.00 CONST.TAX
,nay in any way accrue against said City in consequence of the
gm ting ol'th isp limit. MECH.CONT. LIC.NO. MECH.
'DTAL TOTAL
-_d_ h nature or^ppatcaptomrac Date
INSPECTOR COPY