9312 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT IDENTIFICATION PERMIT NUMBER
BGI DESS APPLICATION & PERMIT 9312
AUI LOIN
1J)Ch,JAA fie
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OwN PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
PHONE 771
NAMEA D OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO, LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S
ADDRESS PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.013 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIc,No. SIGNS TRANS. 3.00
ADDRESS clue. SPECIAL CIRCUIT 5.013 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
ADDREr
SNS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 Il// /I (�
a u b I hereby affirm that I am accessed underprovisionsof Chapter9 ISSUUANCE'DATE-
y "' (ennmencing with Sction]000)of Division 3 of the Business and
Q a BLDG. ELECT PLG. MECH.
H i Professions Code,and my license is in full force and effect. ❑ ❑ ❑ ❑
O 0 H W License Class Lia Number
Date Contractor
y E BUILDING PERMIT
Ic w u OWNER-BUILDER DECLARATION INFORMATION
AOu MISC.- REFER TO ORD
w 3 LL H 1 Imreby affirm that I am exempt from the Contractor's License VALUATION $/FT.
Hyo J Law for the following reason(Sec.7031.5,Businessand Professions pERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
R ¢ ¢0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
O LL req air's the applicant for such permit to file a signed statement that TOTAL PERMIT TO
a w $ he is licensed pursuant to the provisions of the Contractor's License
PC
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
Business and Professions Code)or that he is exempt therefrom and OTY, PLUMBING PERMIT .FEE
r Oo the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
in 5-: by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500).1:
D I,as owner of the properly,or my employees with wages us BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the s 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 not apply to an owner of
property who builds or improves thcrcon,and who does such work FIXTURES-PER TRAP 5.00 SQ FT.FLOOR AREA TOTAL ACREAGE
O mats re Out
hde ownemployees.for Sale
If,ed ever,the
improve GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
mans are not intended or offered for sulc.If,ed that s the building
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
prove for purpose of Sale.). El ❑ El .❑ El
1,as owner of th
e property,am"elusively contracting with INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC5 V.B. ,6.00 ASSESSORS PARCEL NO.
and Professions Code. rhe Contractor's License Law does not apply
to an Owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
0 1 am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
ry
WORKS RS'COMPENSAT ION DECLA RATIon WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate of consent to self-insane, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,LAC.).
Policy No. Company
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant v❑ N❑ v ❑ N❑
CC to CERTIFIC1TC 01'EXE MPT ION FROM WORKERS' PERMIT ISSUANCE 10.00 dL FLOOD ZONE A..L.U.C.
LU > COMPENSATION INSURANCE PLG.GONER. LIC.NO. PLG.
CLaCL Z This section teed not be completed if It,, permit is for one TOTAL E]v N❑ v ElN❑
hundred dollars(S 1001 or less.
U 0 1 certify that in the performance of the work for which this per. OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
O L) become subject to the Workers'Compensation Laws of California. BUILDING
C_ Date Applicant ALTER OR ADD TO MECH. 5.00
} to NO'T'ICE TO AI'I'LICAN'I'. If,after making This Certificate of I's.
I F ? emptinn,you slmuld hecome subject to the Worker,'Compensoioll APPLIANCE 5.00 PLAN 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 10A00C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the P"Romance 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
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• infornmion is correct. I agree to comply with all city nn I county PLUMBING CrV
ordinances and slat laws relating to buildingconstruction, end BOILER-COME(3 H.P.or 100,000 B.T.U.) 6.00 //
hereby authorize representatives of This city to enter upon the r
above mentioned property for inspection purpous. BOILER-COMP Cover,100,000 BTU)SEE FEE SCH. MECHANICAL
(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
may in any way accrue against said City in consequence of the
gOuaR it this P aIR MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
S
ore oVAElplicant/Contraeftor
INSPECTOR COPY