9193 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
OLL ADDRESS APPLICATION & PERMIT
_ 9193
7 ADDRESSSS
BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
D PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
® ALI ONE
NMEA off OUTLETS-SWITCHES-RECEP 10.00/1.00
uC.NO. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
ooaessORS APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
OgcHITECT ., PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE D.C.NO.
ENGINEER i
LIC.No. SIGNS TRANS. 3.00
nooaess ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
Z11 TEMP.METER OR POLE INS. 20.00
APPLICANT'S
ADDDRESSDRESSMOTORS SEE FEE SCH.
V O�
SERVICE CHANGE 20.00 /
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 fa/�/((�
f Z w 1 hereby aflinn
that I am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F w Lic
i Professions Code,and my license is in full force and effect.
z o m ❑ 1:1 ❑ ❑
- mue Class Lie.Number
w w Date Contractor
F ~
Q Y 4 J BUILDING PERMIT
¢ ¢ w OWNER-BUILDER DECLARATION
uAxi 3 A 1 hereby aDinn that I am exempt from the Contractor's License
MISC.- REFER TO ORD INFORMATION
Fool Law for the Followimyreason.(See 7031.5,Businessand Professions PERMIT ISSUANCE 1000 VALUATION i -$/FT-
m i Code:Any city(it county which requiresa Permit to construct.alter,
¢ Q 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
wDLL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO p
$ he is licensed pursuant to the provisions of the Contractor's License
F z Q
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthedG�CQ
f ¢ D Business and I'rofcssions Coder or that he iscxcntpt therefrom and QTY. PLUMBING PERMIT FEE /3L �i7' .460,
¢ F o Ole basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
s
c by any applicant for a permit subjects the applicant toe civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500).1:
❑ I,as owner of the property,or 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 (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
properly who builds or imprints Dtercon,and who does such work FIXTURES-PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
menu ire not intended or offered for sale.If,Imweverrsthc building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im - .- BUILDING USE
prove for purpose of sale). ' INDUSTRIAL WASTE INTER. 30.00 RES IND CDN PB Oer
❑ I,as owner of the properly,ans exclusively.cauracting with m❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code The Contractor's License Law does not apply
to an nwncr of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractor(%)licensed pursuant to
the Contractor's License Law, SEWER-SAN ITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec.-.B.&P.C.for this
Cason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00
.o- ACG DATE ACC.FILE NO.
WORKHRS'S 1pENSAI'IOI LnknT10N WATER TREATING EQUIP. 5.00 ./
I hereby affirm that I have a certificate of consent to wR-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy Nn. Company
O ❑ Certified copy is hereby furnished.
Z Z ❑ Certified copy is fled with Om FIRE SPRINK ENERGY T 24 city inspection division. MISC.- REFER TO ORD.
O Applicant y❑ N❑ y ❑ No
CC T C iRTIFICATF:OF IiXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W 1 COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
d (Phis Section need not be cwnplcted if the permit is for one r TOTAL Y❑ N❑ Y ❑ N❑
Z hundred dollars 1$100)or IL.r
U O I certify that in the performance of the work for which this per OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mil is issued,I shall not employ any person in any manner so as to
because subject to the Workers'Compensation Laws of California.
y DAL Applicant ALTER OR ADD TO MECH. 5.00 BUILDING .LJ
} 0NOTICE TO APPLICANT: If,atter making III,,Certificate of Bx-
♦- Z emplion,you should become subject to the Workers'Compensation 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 10=CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=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 1'nr 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 state that thcabove VENTI LATION FAN (SING LE) 4.00
• infounmion is correct.I agree to comply with all city and county PLUMBING
ordinances and slate laws relating to building construction. and BOILER-COMP(3H.P.or100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOI LER COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep h:mnless 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
granting of this permit. MECH.CONT. LIC.NO. MECH.
� OTAL TOTAL
regK or.App call[0167e=10,
n1 a a
INSPECTOR COPY