8741 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBERAPPLICATION & PERMIT
BUILDINGDOREss ✓ A
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 871,
4
S PLAN CHECK VALIDATION
NA E QTY. ELECTRIC PERMIT FEE
), 'P ONE
CAME CITARs OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO. LIGHTING FIXTURES 10.00/1.00
CDERIESSNTRACPR's
AooREss PPLIANCES-RESIDENTIAL 4,00
PHONE PANELS 10.00 DATE OF APPLICATION
RHLUITECT PANELS OVER 200 AMP) 20.00 PLAN CHECK FEE V.C.NO.
OR
ENGINEER -
uc.No. SIGNS TRANS. 3.00
ARCH,OR ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION '
ZIP EMP. METER OR POLE INS. 20.00
AMOTORS SEE FEE SCH.
ADDDRESSDRESS V �J
SERVICE CHANGE 20.00
,00 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a u a I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
ar,
La with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r o z Concssions Code,and my license is in full force and effect. El ❑
ContractorZo 0 w W License Class Lie.Number
Dale Contractor•Q yf J
EE at 4 OWNER-BUILDER DECLARATION BUILDING R IT
E,
a o INFORMATION
"w r I hereby affirin that I am exempt HOLH the Contractor's License MISC.- REFER TO ORD
u o j Law for the following reason.(See.7031.5,Businessand Ponfessions VALUATION $/FT.
H _ PERMIT ISSUANCE 10.00
Code:Any city or county which requirese permit to construct,alter,
K Q Q improve,demolish,or repair any slrmture,prior k.its issuance,also ELEC.CONTR. LIC.N0. ELEC.
D ¢ requires the applicant for such pereir to file a signed statemunt that TOTAL
u w m m he is licensed pursuant to the provisions of the Contractors License PERMIT TO
Hi >
Law(Chapter 9(commencing with Section 7000)of Division 3ofthe
4 Business and Professions Code)0r that he is exempt therefrom and CITY- PLUMBING PERMIT FEE
o the basis for the alleged exemption.Any violation of Section 7031.5 SID50 I Y PETLONISTRJ
to by any applicant fora Permit subjects lhC applicant maeivil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ 1,as owner of the property,0r my employees with wages as BACK FLOW'PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work.and the structure is not
intended or Offered for sale (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractors 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 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
Firmsarenotintendedoroffered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
TV for purpose of,.F,r. INDUSTRIAL WAS E INTER. 30.00 ;RES IND CON PB Other
1,as owner of the property,am exclusively contracting with ❑ D ❑ 11 D
cd sed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
anProfessions Code:I'he Contractor's License Law does not apply
to i nowner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
tom acts lorsueh projects with a eontruc[ods)licensed pursuant to
tie Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ l am exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 6.00
"Non
Ower Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSAI ION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby u111rm that I have a certificate of consent to ml(-insure, ZONING
or a c,rtificri of Workers'Compensation Insurance,or a exHified ENG.SITE NO,
copy thereof(See.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished. 4 FIRE SPRINK ENERGY T 24
z Z ❑ Certified copy is Filed with the city inspection division.
O Applicant MISC.- REFER TO ORD. Y � NV [] N�
w CERTIFICATEOF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FL000 ZONE A.L.U.C.
W > CO,MPI MATION INSURANC17 PLG.CONTR. LIC.NO. PLG. N C] V ❑ N
CL ❑
Z -YE](This section need not be completed if the permit is for one TOTAL
hundred doll...(9100)or IcssJ
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FE FEE SUMMARY
LL H not is issued, 1 shall not employ any person in uny manner so as to
❑ become subject to the Workers'Compensation Laws of California.
a Date Applicant ALTER OR' DO TO MECH. 5.00 BUILDING
} rn NOTICE TO APPLICANT': If,alter making this Certificme of Ex-
f" Z_ emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 'AN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U 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 IOVER 110MC.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a consvuction 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(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that l have read this application and'fate 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-COMPI3H.P.or100,000B.T.U.) 6.00
Hereby authoriec representatives of this-city to Lute, tenon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-meotinned 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 NST.TAX
M' may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.0
granting of this permit. MECH.CONT. LIC.NO. MECH.
TOTAL are TOTAL
Sig o App nt
want/Coac Date / `+
INSPECTOR COPY '