9261 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS lei b
A ^
`te
i.
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
E / - PLAN CHECK VALIDATION
rvaM QTY. ELECTRIC PERMIT. FEE
• PHONE
UTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
U ry AC o
ADDRESS APPLIANCES-RESIDENTIAL 4.00
S' PHONE2 PANELS 10.00 DATE OF APPLICATION
P ITEC
OR-
PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.N0.
ENGINEER
' LIC.No. SIGNS TRANS. 3.00
moo ESS ENGSPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP frEMP.METER OR POLE INS. 20.00
ADDRESS rS MOTORS SEE FEE SCH. k
ADDRESS SERVICE CHANGE 20.00 p (,
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
".,I I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
ti rt a (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H y Professions Code.and my license is in full force and effect. ❑ ❑ ❑
z O w - License Class I Number
o v, r Dale Contractor
a y f b WCntnr- a BUILDING PERMIT
M ¢o i U WiR-BUILDER D - INFORMATION
wq LL r • I hereby affirm that 1 am exempt front the Contractor's License MISC.- REFER TO ORD
Fu0< Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION g/FT.
a Code:Arycity or county which retluires a permit to construct,alter,
BE
a, a p 'improve,demolish,or repair any structure,prior to its issuuner,also ELEC.CONTR. LIC.NO. ELEG ))
I] ¢ requires the applicant for such permit to file a signed statement that TOTAL rx�
n w m y he is licensed pursuant to the provisions of the Contractor's License PERMIT T
F z a Law(Chapter9(commencing with Section 7000)of Division 3 of the
Ousiness aur Professions Code)or that he is exempt therefrom and' QTY. PLUMBING PERMIT FEE
¢ r c the basis for the alleged exemption.Any violation of Section 7031.5 5 R TR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(S500).1:
❑ 1,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 PTfCSslmns DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractors 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
nuents fonorintende ownemployees.In,side.
11,howeversuch imprmo- GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
menfs aro not intended nr offered y sale II',however,the owner-
or improvement is e b within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE Y.
builder will have the burden of proving that he did nm build or im-
prDeI,aso nee of Bale). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Olner
❑ d as owner of the property, he exclusively . 7044,Bu with ❑ ❑ ❑ ❑
licensed contractors od to construct the project(Sec 7044,Business LAWN SPRINKLERS-1 INC 5-V:B. 6.00 ASSESSORS PARCEL N0.
and Professions Code: Contractor's License Law docs not apply
In an owner of property
who builds
or improves thereon,and who LAWN SPRINKLERS-OVER 5IEA.) 1.00 '
contracts for such projects with a contractors)licensed pursuant to
IIIc Contractor's License Law. SEWER-SANITARY-STORM EA.200itI10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,B&P.C.I'or this WATER HEATER W/VENT 6.00
reason
Owner Dale WATER SYSTEM 5.00 ,�-av ACC.DATE ACC,FILE NO.
WORK ERS'COMPENSA'FION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm first 1 have a certificate ofconscut Do self-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
ropy thercof(Sec.3800,Lob.C.).
Policy No. Company ; Ssr Ch
Q ❑ Cetlified Copyi9 hcrebyfunvstied//�� // �1//`` FIRE SPRINK ENERGY T-24
Z 2 L7-Ce R,B,J copy is Eled with 1hD409 k;Z4A,n.
O Applicant MISC.- REFER TO ORD. Y ❑ • N❑ Y ❑ N❑
W/ CI:RTI EICAI'E O I'F X I:M PT ION P RO M WO R K Ii RS' PERMIT ISSUANCE 10.00% w FLOOD ZONE A.L.D.C.
U COMiPENSA'PION INSURANCE PLG.CONTR. LIC.NO. PLG.
Z (This section need not be completed if the permit is for one 1TOTAL S Y[:] N❑ Y [:] N❑
( hundred dollars(5100)or less)
U O 1 cerfify (hut in the performance of the work for which cis per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
U F- mit is issued,I shall not employ any person in any manner so us to
Uw become subject to the Workers'Compensation Laws of California. BUILDING
o- Date Appllcaln ALTER OR ADD TO MECH. 5.00
` } 2 NOTIC17 '1'0 APPLICANT: If,after making this Certificate of fix- -
F _ 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 t such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONST RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10SWC.F.M.) 6.00 SEISMIC FEE 6�
1 hereby affirm that tier, is a construction lending agency fur EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(See. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Name der's N
LenHEATING UNIT(OVER 100,000 B.T.U.)Leder'same ELECTRIC f[ �
I certify that l have readtris application and state 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-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon tire
abovenhenfioned property for inspection purposes BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
-
(We) agree to Base, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way come against said City in consequence of the PERMIT ISSUANCE 10.00
sixgaoling od his n i1. MECH.CONT. LIC.NO. MECH.
OTAL TOTAL
Ap
Si - a ractor DatC
INSPECTOR.COPY '