9329 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
So LONG APPLICATION & PERMIT
ADOREss
M a ` BUILDING - ELECTRICAL-PLUMBING-MECHANICAL9329
OWNERS PLAN CHECK VALIDATION
Lim.
• NAME � QTY. ELECTRIC PERMIT FEE
orvE
NAMERACTOR UTLETS-SWITCHES-RECEP 10.00/1.00
C.No, C LIGHTING FIXTURES 10.00/1.00
ADDRESS,o cTORs PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ORD"I E PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
• LIC.NO. SIGNS TRANS. 3.00
ADDRESS ENG SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
AAPPLICAr$
DORESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
w w o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
U I hereby w tirin that 1 am licensed under provisions of Chapter 9 y ISSUANCE DATE
w fcommenci ng with Section 7000)of Division 3 of the Rosiness and
rn ¢ n BLDG. ELECT. PLG MECH.
F w i Professions Code,and my license is in full force and effect -
i O a - License Class 2,J Lic.Number t•
O m Doe Contractor
x E BUILDING E IT
co a ° OWNER-IIUILDGR DELLA RA'f10N INFORMATI
F
3 LL I- 1 hereby aflirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
ac v, Law for the following mason. 7031,5.Rusinessand Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
Code:Any city or county whiehrequiresa permit toconstruct.tlter,
¢ rc Q o infprove,demolish,or repair any structure,prior to its issuance,also ELEG.CONTR. LIC.NO. ELEG.
q c to requires the applicant for such permit to file a signed statement that TOTAL PEUMIT TO
n w m w he is licensed pursuant to the provisions of the Contractor's License
F z
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
M H a the basis for the alleged exemption.Any violation ofSection 7031.5 0 P O TR.
ate _ by any applicant fora permit subjects the applicant toacivil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five bundled dollars(S5000.):
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEVICE 4.00 OCC.GROUP S.UNITS
their sole compensation,will do,the work,and the slruct re 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 an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 so.Fr.vLooR AREA TorAL AGREACE
• himself re through his own employers.Provided that such in prove-
munprovriotiev intended or"within
roneyar o I f.howeveq the the owner.
GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or builder
will have
is sob within one year of aie did on, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
proveer will have Iof burden of proving that he did not build or int- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 E IND CON v8 Other
❑ 1,as owner of the property,am exclusively comment with . .
❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-I INC 5 V.B. - 6.00 ASSESSORS PARCEL NO.
and Professions Cade:I'hc Contractor's License Law docs not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractorts)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
Cl Iam exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00 ,p
rcuson
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK F:RS'COM PF.NSATION DECI,ARATION WATER TREATING EQUIP. 5.00
I.Im.byaffirm that I have a eWleme of consent nl sd]-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.CJ.
Policy No. Company )
Q ❑ Certified copy is hereby,fu isha�m ..y.µ/� FIRE SPRINK ENERGY T-24
F.Z �3 Cert ifieJ opy is filed pith the city inspection Ilivi.00n. MISC.- REFER TO ORD. ❑ ❑ - ❑ ❑
T A bean( T/ Y N V N
w �. � �/ PERMIT ISSUANCE 10.00
CER KATE OP EXESIPTION FROM WORKERS' FLOOD ZONE A.L.U.C.
LU (/ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLGa. .
= Z (This section teed not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑' N❑
hundred dollars IS 100)or less.)
U 0 1 certify that in the performance of the work for which this per. CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued, I shall not employ any person inyny mamter so as to
O 0 become subject to the Workers'Compensation Laws of Cufl'ornia
O_ Date - Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} w NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F 2 caption,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 permm
it shall he deeed revoked AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LI!NDING AGENCY AIR HANDLING UNIT(OVER 10.0000EM.) 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
amNHEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Names ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
inlonaation is correct. I agree to comply with all my and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or100,000B.T.U.) 6.00
hereby authorize representatives of this city to ruler upon the BOILER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep hunnless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City' in consequence of the
granting of this permit. MECH.CONT. LIC.NO. MECH.
/
L/ TOTAL TOTAL
/ ognatu ppliGant/C Trac or a
\!!! INSPECTOR COPY