9326 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
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BUILDING APPLICATION & PERMIT ��
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
R' PLAN CHECK VALIDATION
NAME CITY. ELECTRIC PERMIT FEE
OrvE
NAME C OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO. ILIGHTING FIXTURES 10.00/1.00
CONTRACTOR
ADDRESS
APPLIANCES-RESIDENTIAL 4.00
CONTRA
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECKFEE P.C.NO,
OR
ENGINEER
LIC.No. SIGNS TRANS, 3.00
Doo ass Erva. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT', MOTORS SEE FEE SCH.
ApDREss I
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
A v U I hereby fl-nor that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
¢ (commencing with Section 7000)of Division 3 of the Business and
A
PLG. M
BLDG. ELECT. ECH.
F m z Professions Code,and my license is in full force and effect. El ❑
o0 m W Licensc Class Lic.Number
ZA Date - Contractor
a y E BUILDING P R IT
¢ M ¢ OWNER-BUILDER DECLARATION
Be w
O INFORMATION
w ;,LL w I hereby allinn that I mn exempt from the Contractor's License MISC.- REFER TO ORD
B_ O¢ Law for the following reason.(Sec.7031.5,Business and Professions VALUATION 5/FT.
y PERMIT ISSUANCE 10.00 -F
Code:Any city or county repair any structure permit to also
¢ X 4 O improve,demolish,or repair any structure,prior t0 its issuance,also ELEC.CONTE. LIC.NO. ELEC.
wO u requires the applicant for such permit to file a signet)statement thin TOTAL PERMIT TO
A he is licensed pursuant to the provisions of lire Contractor's License
F z i
Law(Chapter 9(commencingwith Section 7000)o'Division 3 ofthe
¢ Business and Professions Code)or that he isexempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r o the basis for the alleged exemption.Any violation of Section 703 t.5 TORIEV TYPE CONSTR.
5- by by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN&VENT-WATER (EA.) 5.00
of nut mom than live hundred dollars($5001.):
❑ I,as owner of Ore property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 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's License Law does not apply to a"owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• lumstif or thomgh his own employees provided thatsuch impro B- -11NC.40UTLETS 6.00
-
Divots are not intended or offered for sale.ll',however.the building GAS-EA.SYSTEM
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or im- TO USE
rove for purpose o(sale.). INDUSTRIAL WASTE INTER. 30.00 RES wo eON PB ome,
❑ I,as owner of the property,am ex,1u,vrI,contracting with ❑ ❑ ❑ ❑
'•nsed•contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
a r Ofessions COde:The Contractor's License Law docs not apply
In o owner o!property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
co mets for such projects wf Or a contractor(,)licensed ur,oant to
,lhc 'ontracmr's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 ,TRACT NO. PARCEL NO.
El I�...exempt under Sec. .&P.C.for this WATER HEATER W/VENT 6.00
um
Owner
Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
/ WORKER. OMI'IiNSATION Dlicl.n RATIO WATER TREATING EQUIP. 5.00
hereby affirm that I have a certdihrte of consent to sell-insure. ZONING ENG.SITE N0.
o u certificate of Workers'Compensation Insurance,or a certified
copy thereof(See.3800,Lab.C.L
Policy No. Company
0 ❑ CertlfiedcopyishBcbylG,eOhed. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is filed with lire ley fnspectiun division.
MISC. REFER TO ORD.
Q APPlicwll y ❑ ry❑ y ❑ N❑
0 W CERTIFICATE OF EXEMPTION FROM)PORKERS. PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C.
W 7 COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG. y[:] N❑ V[:] N❑
CL Z IThis section need not he completed it the permit is for one TOTAL
hundred dollars IS 100)or less.)
0 O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mf( is issued, I shall not employ any person in any manner w as to
become subject to the Workers'Compensation Laws of California.
Date-Applicant BUILDING
iALTER OR ADD TO MECH. 5.00
} w NOTICE TO APPLICANT''. It,after making IN,Certificate of Ex-
Z_ eruption,you should become subject to Ore Workeri 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=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10)000CF.M.) 6.00 SEISMIC FEE
I hereby utfinn 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,Cis,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 eeftify that I have read thin 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 the BOILER-COMP(Over 100,000 BTU)SEEFEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(Wc) agree to save, indemnify and keep lunatics, 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
grm.tiagofthispeuril. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
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Signature of Applicant/Conlmclor Unto
INSPECTOR COPY