8281 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
aooREss 09 1
/R/l A7 r��• BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 1 8281
OWNER'S - PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
PHONE
CONTRACTOR
NAMERacroRs CIO OUTLETS-SWITCHES-RECEP 10.00/1.00 66
UC.No. v LIGHTING FIXTURES 10.00/1.00 d_�
CONTRACTORS I1 QOS _ PPLIANCES-RESIDENTIAL 4.00 y�Z
ry ;df PHONE , / PANELS 10.00 -n cv DATE OF APPLICATION '
ARCHITECTon PANELS (OVER 200 AMPI 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRESS ENC' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. 20.00
ADDRESSTs � MOTORS SEE FEE SCH. 51
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
¢ o u 1 hereby affirm that I am licensed wider provisions of Chapter 9 ISSUANCE DATE
yz i (commencing with Section 7000)of Division 3 of the Busimss and
¢ BLDG. ELECT, I PLG. MECH.
D"' Professions Code.and raylicense is in fall force'nd c(f {r ❑ ❑ ❑
0 0 w o Licensc Class �OLic,Number
I- w UaleContmctor
Q s, E J 0 4 BUILDING PERMIT
¢ IS
u - OWNER-BUILDER DECLARATION s INFORMATION
w ; u H I hereby affirm that 1 am exempt from the Contractor's License MISC.- ,� REFER TO ORD VALUATION
LL 0 4 Law for the following reason.(Sec 7031.5,Business and Professions PERMIT ISSUANCE 10.00 $/FT.
� _ Code:Any city orcounty whichre9uiresapenmt toconslruct.alter, _
¢ a improve,Demolish,or repair any structure,prior to its issuance.also ELEC.CONTR. LIC.NO.p
ELEC.
n wDrequires the applicant for sock permit to file a signed statement that TOTAL PERMIT TO
LL$ he is licensed pursuant to the provisions of the Contractor's License
Fzi
Law(Chapter 9(commencingwithSection 7000)ofDivision3oflhe ELEG 4
4 Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ r o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a ; �2 by any applicant born permit subjects the applicant to a civil penalty gLTER-DRAIN&VENT-WATER IEA.) 5.00
of not more flum five Imndred dollars(S500).):
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the stmcture is not
intended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractors 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 TOTAL ACREAGE
mentslf re through his own employees.Provided thus such insprove-
nimself a not intended ow employees,
Res,or pe If,howhat s the building GAS-EA.SYSTEM-1 1NC.4 OUTLETS 6.00
or improvement is Sold within one year of completion, - ,1 2.00 the owner- GAS-EA.SYSTEM OVER 4 (EA
builder will have the burden of proving that he did not build or im. BUILDING USE
prove for purpose ofsale.)' INDUSTRIAL WASTE INTER3000 RES IND CON PB Omer
❑ I,as owner of the property,am exclusively contracting with . .
❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code The Contractor's License Law does 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 contraetorts)licensed pursuant to SEWER-SANITARY-STORM EA.200f[/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ lumexomptundnr Scc. .B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
1 hereby affirm that I hdve a certificate of consent to self-insure. ZONING ENG.SITE N0.
or a certificate of Wor Ijj Cz� e8TOL,Insurance,or a certified
Copy thv,vo _J Ki11C�. P
Policy No. COIpPany LC(�(,i
O ❑ Certified copy is hereby furnised. FIRE SPRINK ENERGY T 24
Z 2 ❑ Certified ropy is tiled with the city inspection division.
Q Applicant Tei Mn - - a 1. s / _ MISC.- REFER TO ORD. v ❑ N❑ v ❑ N❑
~ y' PERMIT ISSUANCE 10.00
cc - CIiRT11o1C1 EXEMPTION FROM WORKERS FLOOD ZONE A.L.U.C.
W > COMPENSAT'ION INSURANCE. PLG.CONTR. LIC.NO. PLG.
EL EL 0 This section need not be completed if the permit is for one TOTAL V❑ N❑ Y ❑ NE]
hundred dollars(S 100)car Ivx J
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I Shall not employ any person in any mourn,so as to
Ow become Subject to the Workers'Compensuticn Laws of California. BUILDING
a, Date Applicant ALTER OR ADD TO MECH. 5.00
} 0 NOTICE TO APPLICAN f: If,after making this Certificate of Ex
F ? emption,you should become subject to the WorkersCompensation APPLIANCE 5.00 PLAN CHECK
Provisions of the Labor Code, you must forthwith comply will, FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000QF,M) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10SMC.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(Sec. MICROFILM
3097,Civ.C.). H EATING UN IT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
n
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
ordinances n correct. I agree to comply with all city and county PLUMBING
ordinances and state lows relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this coy to enter upon the BOILER-COMP (Cunr 11X),100 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property 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 PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
granting of this IiL MECH.CONT. LIC.NO. MECH.
�-7/ 1 TOTAL TOTAL
Signat f l I ant/Contractor Date
IV INSPECTOR COPY