9429 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT ^ g ��
ADDRESS y(�,
BUILDING- ELECTRICAL-PLUMBING-MECHANICAL
O N 'S PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
�lAkL
PRONE'1411
aci0 s
NANT UT LE -SW'TC
HES-RECEP 10.00/1.00
LIC.NO. LIGHTING FIXTURES 10.00/1.00
ADDRESS APPLIANCES PPLIANCES-RESIDENTIAL 4.00 -
CONTRACTOR
PRONE PANELS 10,00 DATE OF APPLICATION
OR
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE v.c.No.
ENGINEER
LIC,NO, SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
ADDDREDRESSS S
AMOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 /�/
0 0 o LICENSED CONTRACTORS DECLARATION TEMP, POLE 30.00
HK u I herehy affirm that 1 ani licensed under provisions of Chapter 9 ISSUANCE DATE
G H (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLC. MECH.
H a z Prokssions Code,and my license in full trace and effect.
❑ ❑ ❑ ❑
o 0 vi W License Class Lic.Number
Date Contractor
Q y E J
a: a OWNER-BUILDER DECLARATION BUILDING PERMIT
¢o u o INFORMATION
w ; LL H I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u o¢ Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
r - Code:Any city Or county which requiresa permit to construct.alter,
Se ou 4ar 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
Q requires the applicant for such permit to lite a signed statement that TOTAL
w m m he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
Hi> Law(Chupler9(commencingwilll Section 7000)o'Division 3 of the (s
R Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE �7 ���rf{
It =$ the basis for the alleged exemption.Any violation of Section 7031.5 STORI 5 TYPE CONSTR.
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(5500).1:
❑ 1,as Owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 DCC.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', License Law does not apply to an owner Of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such Improve.
menu are not intended or offered for sale.If,however.lire building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of rocompletion, the owner- GAS EASYSTEM-OVER 4 IEA.1 2.00
builder will have the burden of proving Out he did nal h - .uild or im- BUILDING USE
RES IND CON PB Other
prove fors owner of sale.). INDUSTRIAL WASTE I NTE R. 30.00
❑ L c owner contractors
the properly,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors: I construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC S V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The who
builds i License Law dons not apply
to tr owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for penseeswith a mmnmtorls)licensed Pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
Ilia Contractor's
s LLicense Law. -TRACT NO. PARCEL N0.
❑ rum cxcn) Lund Scc. ,BARO for 1L WATER HEATER W/VENT 6.00
reason
Uwner DW WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WO I,
. Cjul
OMPENSATION DECL/kA'I'10 WATER TREATING EQUIP. 5.00
Ulmrchy uf0 that 1 have certificate of consent to self-insure.
or a"rtificate of Worked Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy ihereof(Sec.3800,Lab.C.)
Policy No. Company
U ❑ Certified copy is herehy furnished.
FIRE SPRINK ENERGY T-14
Z Z 71Certified copy is filed with the city inspection division.
O Applicant MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ ' NE] '
SCC CERTIFICAT lIPEKSATION INSURANCE
i OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.G.
LU > COSPLG.CONTR. LIC.NO, PLG.
CL Z( This section need not be completed if the permit is for one TOTAL Y❑ NE] Y E] NE]
hundred dollars IS 100)or less.)
U O I certify that in the pert Urmance of the work for which this Per, QTY. MECHANICAL PERMIT FEE FEE SUMMARY
IL H out is issued.I shall not employ any parson in any munner so as to
O become subject to the Worked Compensat ion Laws of California.
U.1
Dawn Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
�- to NOT'ICIi TO APPLICANT: If,after making this Certificate of Ex-
� Z emption.you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE 6 J
U such provisions or this permit shall be(learned revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 �'-
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE SO
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.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender Address HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that l have read this application and state lhattheebove 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-COWf3H.P..r IOO,000B.T.U.I 6.00
hereby authorize representatives of this city to enter upon the gQILER-COMP(Over 100000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly for inspection purposes.
(We) agree to save, indemnify mrd keep I pates, the City of IS
,- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any ay Seer a against said City in consequence of the
grantingOf . prof . / MECR.CONT. LIC.NO. MECH.
TOTAL TOTAL /7 rw
ont ct
INSPECTOR COPY ,
t I