9366 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI F[CATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
"DRESS 01 yt
/` L BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 9366
0 N 'S ,,/ ou< PLAN CHECK VALIDATION
k NAME OTY. ELECTRIC PERMIT FEE
KE
NAME °TOR s' OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS'
ADDRESSDRESSAPPLIANCES-RESIDENTIAL 4.00
PHONE PANELS- 10.00 DATE OF APPLICATION
ARCHITECT - PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT V
ADDRESS SPECIAL CIRCUIT 5.00
ZIP EMP. METER OR POLE INS. 20.00 1111I
ADDRESSurs MOTORS SEE FEE SCH. 6 1989
ADDRESS
a7
SERVICE CHANGE 20.00
BE o LICENSED CON"f RACTORS DECLARATION TEMP.POLE 30.00 City Of cOPBIf;po
UI hereby affirm that 1 am licensed under provisions Of Chapter 9 ISSUANCE DATE
waw (cum meriting with Section 7000)of Division 3 of the Business and BLDG. ELECT. P MECH.
H y z Professions Code,and my license is in full force and effect ❑ ❑
Z o m -' License Class Lie,Number
Ci v, r Date Contractor
a y BE BUILDING MIT
¢ BE BE
¢ OWNER-BUILDER DECLARATION
u INFORM TION
od MISC.- REFER TO ORD
K 1 hereby estrum shot I ng wn exempt from the Contractor's License VALUATION $/FT.
F LL o ¢ Law for Any citfoly
or Countywhi h e,requires
a permit to construct,
Professions PERMIT ISSUANCE 10.00
Code'.Any city or county which sequiture permit to Construct,aalso
Q ¢G improve,demolish,or repair any structure,prior to its issuance also ELEC.CONTR. LIC,N2 ELEC.
o¢ requires the applicant for such permit W file a signed statement that TOTAL PERMIT TO
w0 y Ile is licensed pursuant to the provisions of tire Contractor's License
Ez >
Law(Chapter 9(commencing with Section 7000)ofDivision 3 of the
¢ Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
SE r o the basis for the alleged exemption.Any violation of Section 7031.5 STO ES vPE CONSTR.
a;�2 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(85009.):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP PES.UNITS
their sole compensation,will do the work,and the slmcture MIFF
intended or Offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code: the Contractor's License Law docs not apply,to an owner of
property who builds Or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 So.FT FLOOR AREA TOTALACREAGE
h imself"re of intended
his own employees.Provided that such improve-building
mems are through his ofoffered foremploee sale.Iided thaegtheiBg GAS-EA.SVSTEM-I1NC.40UTLETS 6.00
or urproven[ent is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA,) 2.00 BUILDING USE
huildc,will have the burden of proving,that he did not build or im- R IND CON PB Other
pros for purpose of salol. INDUSTRIAL WASTE INTER. 30.00
'I,as owner of the proVerty,am exclusively contracting with
Iicei contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORSPAHCELNO,
and ofessions Code:The Contractor's License Law does not apply
tu'an wrier of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for at projects with a eontractor(s)licensed par manl to
thi Contra r' Ifor. an,. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ 1 E tp Sade .ea -"C tut WATER HEATER W/VENT 6.00
e'JSOI1
wrier Det, WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a cmtificate'of consent to rel&insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No. Ccn[pany
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T2
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y 0 N❑ Y ❑ N[]
HFL000 zorvE A.L.u.c.
OC N CER'1'1 PICATEFE EXEMPTION I PTIPROM WORKERS' PERMIT ISSUANCE 10.00
CL >_ COMPENSAT'ION INSURANCE
URANCE PLG.coNTR. LIC.rv0. PLG.
11 (This section need not be completed if the permit is for One TOTAL N�
Z) Z hundred dollars IS 100)or less.)
U O 1 certify that in the'performanee of the work for which this nes- CITY- MECHANICAL PERMIT FEE FEE SUMMARY
LL I- Init is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
a Dam - Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} ce NOTICE TO APPLICANT`. If,after making this Certificate of Ex
r Z cmption,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 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000GEM.) 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,Cie C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Leader'.,AddreHEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
ss
I certify that l have read this application andstate he above V ENTI LATION FAN LE) 4.00
that t -
information is correct.I agree to comply with all city and county PLUMBING
ordinances and slam laws relating to building construction, a BOILER-COMPI3 H.P.o1IO0,000B.T.U.) 6.00
hereby aulhorixc representatives of this city to enter upon the BOILER-COMP IOver 100,000 RTu15EE FEE SCH. MECHANICAL
'above-mentioned property for inspection purposes. " --
(We) agree to save, iodefpnify and keep harnmess the City of MISC.- REFER TO ORD.
Cupertino ainst liabilities,j7dgments, costs ism expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in n a a rue against said City in consequence of the
grant go his a 't MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL /
SiWtLWj ff1iE5nf7ConImmor Date 1 _q
INSPECTOR COPY
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