11213 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
—/ BUILDING
APPLICATION & PERMIT
�T ADDRESS/OBUILDING —ELECTRICAL—PLUMBING—MECHANICAL 11213
OWNER'S - - PLAN CHECK VALIDATION
NAME A/ },(/ TV. ELECTRIC PERMIT FEE'
1/V PHON V
CONTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00 O "�
NAM qq n� /
c.No. JU9 LIGHTING FIXTURES 10.00/1.00 0
.ONTRACTORS Mt✓ PPLIANCES-RESIDENTIAL 4.00
La
AOOR ESS Z
PRONE PANELS 10.00 GATE OF APPLICATION
AR 07)19 rtECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LOC.No, SIGNS TRANS. � 3.00
ARC H.OR ENG. SPECIAL CIRCUIT S.QQ PERMIT VALIDATION
ADDRESS PAID ID
zIP EMP.METER OR POLE INS. 20.00 . I I��
APvucarvr's MOTORS - SEE FEE SCH. .,L U' I�1
ADDRESS 'Y 71,v
' ' SERVICE CHANGE 20.00
O o LICENSED CONTRACTORS DECLARATION City 01 rs
J li��mw
< u v I hereby affirm that I n licensed under provisions of Chapter 9 ISSUA
w w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F m i Professions Code. d my license is in full fore a d IT ❑
z O w — License Class Lie.Number
O of r w Dalc - Contractor - n/
M a OWNER-BUILD ER DECLARATION l e - BUILDING PERMIT
o act MISC.— REFER TO ORD INFORMATION
E
S u y. 1 hereby affirm that 1 am exempt from the Contractor's License VALUATION $/FT.
u O a Law far the following reason.(Sec 7031.5,Business and Professions PERMIT ISSUANCE - 10.00 l -�
FN0 Code:Any city or county which requires a permit to construct,alter,
Qu,¢ 0 Improve,demolish,or repair any structure,prior to Its Issuance,also ELEC.CONTR. LIC.NO.- ELEC. �] ✓l
El
u requires the applicant for such permit to file a signed statement that TOTAL 3 6 PERMIT TO
wm he is licensed pursuant to the provisions of the Contractor's License
rzLaw(chapter 9(commencing with Section 7000)of Division 3 ofthe ���� IA-46:-
, j
a Business and pudessions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT . FEE
F Oo the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
w. by any applicant for a permit subjects the applicant paneled penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as IBACK 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 (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 does such work ` FIXTURES-PER TRAP 5,00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve.
ments are not intended or offered for salel f,however,the building GAS-EA.SYSTEM-.11NC.40UTLET
or improve romt is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.0101' BUILDING USE
builder will Rave the burden of proving that be did not build or im. RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. lid 30.00
❑ 1,as owner of the property,am exclusively contracting with I` I ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(See. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
no Professions Code:The Contractor's License Law docs not apply
to an owner of property who builds or improves thercon.and who LAWN SPRINKLERS-OVER 6 ) 00
contracts for such projects with a contractors)license.)pursuant to SEWER-SANITARY-STORM EA.20ft/1 .11 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ I am exempt under Sec.—,BAP.C.for this WATER HEAT ER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hemby eff.m that I have a certificate fconsent to self-insure, ZONING ENG.SITE NO.
or a certificate of Worker,'Compensation Insurance.or a certified
copy tiler- �89 0,LabC.).
Policy No �Conl PmIy A'T� /3La✓�'
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY TRA
Z 2 ❑ CerCI�'epp �oyy is f lh the city inspection division.
F Applican /Ad MISC.- REFER TO ORD. y ❑ N❑ y,❑ N❑
rn E// PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.c.
QU
� C R'I'If KATE OP EXEMPTION PROM WORK F.RS'
LL COMPENSATION INSURANCE PLG.CONTE. UC.NO. PLG. /�� Y❑ N❑ Y❑ IN
CL O (This section need not be completed if the permit is for one TOTAL
=) Z hundred dollar,($100)or less.)
U O 1 certify that in the performance of the work for which this per- QTV MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any Intoner so as to
p w become subject to the Workers'Compensation Laws of California. BUILDING
Date Applicant ALTER OR ADD TO MECH. 5.00
>_ N NOTICE TO APPLICANT': If,after making this Certificate of Ex 'ULJ-
F-. ? emption,you should become subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK
,incisions 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 I
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 1o=c.RM.) 6.60 I $EJSMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) D
the-perlormunce of the work for which this permit is issued(Sec. I
tIMICROFILM
3097,Civ.C.). HEATING UNIT(T0 100,000 B.T'.U,) /Lender's Name HEATING UN IT(OVER 100,000 B.T.U.)9.50ELECTRIC 36Lender's Address
I certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00information is correct I agree 1'o comply with all oily and county PLUMBINGordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,0006.T.U.) 6.00hereby authorize representatives of this city to enter upon the BOILER-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 PERMITISSUANCE 10.00 0 — CONST.TAX
mm
may in any way acuo,against said City in consequence of the - -
Bra men lis permit. MECH.CONT. LIC.NO. MECH.
\\h' B6 ! TOTAL �S`'r' TOTAL
gnature of A pplicant/Contractor Date 5 to
OFFICE COPY