9272 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 'Anon
jl ADDRESS / y L r G
/ � q BUNG -ELECTRICAL-PLUMBING-MECHANICAL
OwNER'S1 PLAN CHECK VALIDATION
"AME OTV. ELECTRIC PERMIT FEE
CONTRALTO 'S
NAM T..1G OUTLETS-SWITCHES-RECEP 10.00/1.00
VCox
rri.CC.fYNOO. Q LIGHTING FIXTURES 10.00/1.00
ADDRESS /rOS� PPLIANCES-RESIDENTIAL 4.00 c,
�1
4 r ' PRONE - PANELS 10.00 DATE OF APPLICATION
PORCHITEC1Tr'�1 J q1. JalJ" PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
Ic.NO. [SIGNS TRANS. 3.00
ADDRESS c. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
ADDRESS
S
AMOTORS SEE FEE SCH.
ORE
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 -
< o u I hereby affirm thot,l um licensed under provisions of Chapter 9 ISSUANCE DATE
m< H (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT- PLG. MECH.
R y z Professions Code,and my license is in full force and effect. ❑ ❑ ❑
z o m - Date Class Lic.Number CI
a y Date-
v,
to
-
a M s � BUI ING PERMIT
It M
a V OWNER-BUILDER DECLARATION I FORMATION
K
S a _ I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
a0 ¢ Law for the following reason.(Sec.7031.5.Businessantl Professions PERMIT ISSUANCE 10.00 vAL gTON FT.
- 0 Code:Any
Q Q Q AnYm't or countywhich requires ep oconsa
improve,demolish,or repair a1SlclnfL,priorto ILS issuance,also
ELEC.CONTR. LIC.N0. ELEG
O M requires the applicant for such permit to file a signed statement that TOTAL RMIT TO
a w m he is licensed pursuant to the provisions of the Contractor's License ,
Hzi Law.(Chapter 9(commencing with Section 7000)of Division 3 Lithe
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
FI- o the basis for the alleged exemption.Any violation of Section 7031.5 STO E T E CONS R.
a , .. by any applicant fora permit subjects the applicant too civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(8500).)',
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC GROUP RES.UNITS
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 thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees.provided that such improve-
mems are not intended or offered for sale.IL however the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BULLRING USE
builder will have the burden of proving that he did not build or ins
prove for purpose ofsale.). RES IND CON PB Other
INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑
❑ I,as owner of the property,am exclusively contracting with
licensed contractors to construct the project tSee.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractors License Law docs 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
t he Contractor's License Law. TRACT NO. PARCEL NO.
❑ tum exempt under Sea ,B.AP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSA'I'ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to selfinsure,
` or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec 3800,La>CA
Policy No ny
Q P-Cert(let y'fcru'llct. �M FIRE SPRINK ENERGY T 24
Z 2 O Cetlifie I ded with
O rlpPlicuntX thy/mty mspeaion division.
- MISC.- REFER TO ORD. Y❑ No Y ❑ N❑
F- w PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.uc.
� \ CERTIFICATE OF IiXh NPT10N I'ROh1 WORKERS'
W 7 \, l COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y❑ N❑ Y ❑ N❑
CL 0 (Thi`, section need not he compewd if the permit is for one _ TOTAL
hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- OTV. MECHANICAL PERMIT FEE FEE SUMMARY
0 H mit is issued.I shall not employ any person in any manner so to
O W become subject to the Workeri Compensation Laws of California.s
a Umc npphc°nl ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE TO APPLICANT: If,after making this Certificate of lis.
F 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 -
U such Provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10SMC.F.W 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER tOPMC.EM.) 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 for which this permit is issued(Sec. MICROFILM
3097,Civ.C.), HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's e
am
NH EATI NG LIN IT(OVER 100,000 B.T.U.)9.50
Lender's Name ELECTRIC
1 cloth, 0mt 1 hove read this 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 80ILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby outhorim representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
ahove-mentioned properly for Inspection purposes.
(We) agree to save, 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 accrue against said City in consequence of the PERMIT ISSUANCE 10.00
gr\utg oftt. MECH.CONT. LIC.NO, MECH.
7-it-d)� TOTAL TOTAL
41\s,x_
Sl Fre Applicant/Conlracffir' a alb
1 INSPECTOR COPY