8537 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
AOO Ess
R/) BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 853
O ER •v PLAN CHECK VALIDATION
A rTQTY. ELECTRIC PERMIT FEE
} L UAI vRONE I[j V�
NE AcI'ORs UTLETS-SWITCHES-RECEP 10.00/1.00
sec.No. LIGHTING FIXTURES 10.00/1.00
CONTRAGTRAC
ADDTora DRESS PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHEETF7 P.C.NO.
OR
ENGINEER
LIC.No. SIGNSITRANS. 3.00
00 Ess ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
` zIP EMP.METER OR POLE INS. 20.00 k
ASMOTORS SEE FEE SCH. T
ADDRESS
-
SERVICE CHANGE 20.00
ww o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a uI hereby affirm thatI am licensed under provisions of Chapter 9 ISSUANCE GATE
'a (commencing with Section 7000)of Division 3 of the Rosiness and
G y T BLDG. ELECT. PLG. MECH.
Z F w¢ z Professions Code,and my license is in full force and effect. - _ ❑ ❑ ❑
,A ;
License Class Lie.Number
-
F, wo H Dale Contractor 'L
a m E BUILDING PERMIT
¢ ¢ ¢ OWNER-BUILDER DECLARATION
¢ w u INFORMATION
se ;aL y I hereby affirm that I am exempt from the Contractors License MISC.- REFER TO ORD
w o¢ Law for the following reason.(Sec.7031.5,Business and Professions .PERMIT ISSUANCE VALUATION $/FT.
t_ - -` Code:Any City or county which requires a permit to Constructalter,
¢ 4 2 improve,demolish,or repair any structure,Prior to its issuance,also ELEC.CONTR. LIC.NO.
ELE0. 2J
o u requires the applicant fur such permit to file a signed statement that TOTAL '� PERMIT TO
w m he is licensed pursuant to the provisions of the Contractor's License
ea z i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
4 o
thBusiness and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ 1- m e basis for the alleged exnnption.Any violation of Section]031.5 STORIES TYPE CONSTR,
ate _ by any applicant fora permit subjectstlm applicant fou civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars(3500).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 Hit sale(Sec. 7044. Rumness and Po,fcssiousDRAINS-FLOOR,ROOF,AR EA,GOND. 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 re through his own employees.provided that such implore-
muslfOrthnotighriot dud oroffered mplyees.or ,.cidCd that
the building GAS-EA.SYSTEM-1INC.4OUTLETS 6.00 //5i
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or int- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ r ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:'I'lie Contractors License Law docs nut apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts for such projects with a contmctorfs)licensed pursuant to
the Contractors License Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. - PARCEL NO.
0 ri exempt Orders WATER SYSTEM 5.00
,B.&P.C.I'or this WATER HEATER W/VENT 6.00
leas()
\/
Own Dal ACC.OATE ACC.FILE NO.
'rx
'ORKERS'COMPENSATIOpf :CLARATI N WATER TREATING EQUIP, 5.00
I e yaffirm that I have a certif/M1i c of consent to self-insure, x
or a certificate of Workers'Compensation Insurance or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Ub.CJ. I
Policy No. Company
O Cl Cerlilied copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is filed with the city inspection division.
O Applicant MISC.- REFER TO ORD. YE] NQ Y ❑ N[]
CC y Cl:RTI FICA 11:017 EXEMPTION FROM WORKERS' PERMIT ISSUANCE -ID.BO FLOOD ZONE A.L.II.C.
W > COhiPFNSAl DON INSURANCE PLG.CONTR. LIC.NO. PLG. / v❑ N❑ YE] N❑
Z (This section need riot be completed if the permit is for one TOTAL 0
hundred dollars IS 100)or less-)
U O I certify that in the performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F not is issued, I shall not employ any person in any manner so as to
O w hecome subject to the Warkeol Conmcrralion Laws of Calitornia.
D. Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} res NOTICE TO APPLICANT: If,after making this Certificate of Es-
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 he deemed revoked AIR HANDLING UNIT(TO 10MC.F.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 for which this permit is issued(Sea. 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 6 .�
Lender's Address ELECTRIC
I certify that l have read this application and state thud lire above VENTILATION FAN (SINGLE) 4.00
infornNiou is correct. I agree to comply with all city and County PLUMBING OG
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 the
above-mentioned property for inspection purposes. BOILER-COMP(Owl 100,0008TU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify unit keep Imrmless the City of MISC.- REFER TO ORD.
Cupertino against liubilifies,judginents, Costs and expanses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
g nlingofthisper MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Xontractor
INSPECTOR COPY