8419 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT 1DENTIFICATION APPLICATION & PERMIT PERMIT NUMBER
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BUILDING-ELECTRICAL-PLUMBING -MECHANICAL 841
1 NAME PLAN CHECK VALIDATION
f OTY. ELECTRIC PERMIT FEE
� PMONE
NAMEA ^Rs UTLETS-SWITCHES-RECEP 10.00/1.00
uc.No LIGHTING FIXTURES 10.00/1.00
A
ADDRESS PPLIANCES-RESIDENTIAL 4.00
/
f' Ory PANELS 10.00 DATE OF APPLICATION
OR PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
uc.NO SIGNS TRANS: 3.00
moo Ess ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
APPLICANTS, MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 a(�
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE ' 30.00 9J�S
¢ v v I hereby affirm that I am licensed under provisions of Chapter J ISSUANCE DATE.
v, w fcon ineneing wil11 Section 7000)of Division 3 of the Business and
Z a BLDG. ELECT. PLG. MECH.
H H z Professions ,- nd my lift Ise n et(all for a und.cIf eet 'y ❑ ❑ ❑
Z o ut - License Class Lie.Numbe _ 0 .
9 r or Date�/ Contractor
a a BUILDING PERMIT
¢ ¢ ¢ W F,R-tl UI1.DIiR DEC1.A ATION
¢ w D INFORMATION
oo. MISC.- REFER TO ORD
E
3 n- H hereby affirm that 1 am exempt from the Contractor's License VALUATION SIFT.
F .. o¢ Law for the following reason.(Sec.7031.5,Business anJ Professions PERMIT ISSUANCE 10.00 _
P, m 4 Code:Any city or county which requiresapermitto construct,alter,
ce ¢ ¢D Improve,demolish,or repair any structure,prior to its Issuance,also ELEC.CONTR. LIG NO. ELEC.
O u requires the applicant for such permit DI file a signed statement that TOTAL PERMIT TO
R
$
As he is licensed pursuant to the provisions of the Contractor's License �CyQup,Z
Hz >
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he isesempt therefrom and QTY. PLUMBING PERMIT FEE
¢ f o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not nwre than five hundred dollars IS500).1:
❑ I,as owner of the properly,or my employees with wagcsas BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the sl ructure 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 Tint apply to an owner of
properly who builds of Improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTALACREAGE
• himselfIs re through)its owmmored for spnrvid edthussu such imilding
mmselfo throuh)itsot or offered provided
that r.such bolding GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion.One owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING UBE
builder will have the burden of proving that he did not build or im
Prove for purpose of sale.). INDUSTRIALWASTE INTER. 30.00 RES IND CON Pe Other
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors ID construct the project(Sec. 7044,BusinessLAWN 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 IEA.) 1.00
contracts forsuch projects with it contractors)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under See.-,B&PC,for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILENO.
WORK CRS'CONIPF-NSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby allurn that I have a certificate of consent to self-insure. ZONING
or a certificate of Workers'Compensation Insurance,(it a certified ENG.SITE NO.
copy thereof(Sce.3800,Lob.C.).
Policy No. Compm����
U ❑ Cerilied copy C mpar u
FIRE SPRINK ENERGY T-24
Z C3Certified copy is Filed with the city inspection division. MISC.- REFER TO ORD.
Oi'� Applicant - Y ❑ IN Y ❑ N❑
� N CERTIRCAI'COF ERHMPTION FRONI WORKERS' PERMIT ISSUANCE 10.00 FLooDzoNE A.L.uc.
LU > COMPENSATION INSURANCE PLG.CONTR, LIC.NO, PLG. V❑ N❑ Y ❑ N❑
O (Phis section need not be completed if the permit is for one TOTAL
Z hundred dollar'1$100)or loses.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in any manner so as to
U Qbecome subject to the Workeri Compensation Laws of California.
no no Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} m NOTICE TO AI'I'LICANT': 11,alter making this Certificate of nix-
♦- ? emption,you should become subject to(lie Workers'Connpensalion APPLIANCE -5.00 PLAN CHECK
provisions of the Labor Code, you must lorthwlth comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1Q,000CF.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIRHANDLING UNIT(OVER I0,000OF.M.) 6.00 SEISMIC FEE ]f'
1 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.). Y H EATI NG UN IT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATI NG UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
• Lender's ABJres.
I certify that I have read this applicationand state IIIu t the above VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city and county PLUMBING
'ordinances and state laws relating to building construction, and BOILER-CIXv1P13H.P.or100,0008.T.U.) 6.00
hereby authorize representatives of this city be enter upon the BOILER-COMP (Over 100.000 BTUI SEE FEE SCH. MECHANICAL
above ncriboned property for inspection purposes.
(We) agree to ave, indemnify end keLf harmlcv the City of MISC.- REFER TO ORD.
Cupertino against iabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
in any wa accrue against said City in consequence of the
nti f this unit. MECH.CONT. LIC.NO. MECH.
nd TOTAL TOTAL 7d o2.�
clor
-Date
INSPECTOR COPY
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