9311 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY ^ 9
BU LDI NG PROJECT I DENTI FI CATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 931
ADDRESS y
BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
O E 5 PLAN CHECK VALIOATION
NAME QTY. ELECTRIC PERMIT FEE
PHONE I
TTRncTo
NAME UTLETS-SWITCHES-RECEP 10.00/1.00
4 LIGHTING FIXTURES 10.00/1.00
ND.
co TRACT
AooEEss PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
A PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR SU IJtz4V ALL
ENGINEER
uc.No. SIGNS TRANS. 3.00
ARC",On END. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
SS -ZIP
EMP. METER OR POLE INS. 20.00
APPLICANTSMOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.0 qq
wo o LICENSI'DCON'�'RACTORS DECLARATION TEMP.POLE
a O U I herebyaffirmthat I am licensed under provisions of Chapter9 ISSUANCE DATE
v, ¢ w irmah ocimg with Section 7000 of Division 3 of the Puniness and BLDG. ELECT. PLG. MECH.
F y z I'rofessions Code,acid any license is in full force and effect.
z
9 0 m - License Class Lia Numbe�-_� ❑ -. ❑ ❑ ❑
z r Uutc Contractors 1
a y E BUILDING PERMIT
¢ Iew ¢ OWNER-BUILDER DECLARATION INFORMATION
OAU MISC.- REFER TO ORD
se 3 a- I I hereby affirm that I am exempt from the Contractors License VALUATION SIFT.
as
H LL o a Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter, 9
QQ Q Q Improve,demolish,or repair any Structure,prior to Its issuance.also E C.CONTE. LIC.NO. ELEC. G
or
- O W requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
A w m" he is licensed pursuant to the provisions of the Contractor's License �a
H•ZY
Law(Chapter 9(commeneing with Section 7000)of Division 3 ofthe (Jfj 7_11e,0M E
¢ 1usiness and Professmov Codc)or that he is exempt thcreliom and Q Y. PLUMBING PERMIT FEE
¢ ti o the basis for the allc,,d exemption.Any violation ofSection 7031.5 STORIES TYPE CONSTR.
dam _ by any applicant fora pemtit subjects the applicant too civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(S500)J:
❑ 1,as owner o ,the property.or my employees with wages as BACK F LOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure Is not -.
intended or offered for sale (Sea 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Cuntractq*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 TOTALACREAGE
himself re through his own employees,provided that such improve-
mniselfeats enot inghhis or ffc,cd for employeesa e.provided
that
building GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or improvement Is sold within one year of completion.tine owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the limen of proving the he did not build or im-
prove l'or purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
❑ I,as owner of the property,a 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 therm�y?t,vyl D LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contracmr(s)licensed pub atit to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
O I am exempt Under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Dam WATER SYSTEM 5.00 ACC.DATE ACC.PILE NO.
WORK ERS'COMPENSATION DECLARA'f10N WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to acll-ins o,. ZONING
or a certiliWte of Workers'Compensation Insurance,or a certified. ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No.-C(...J,mhyr__2I:OT n HERR GA 1
O ❑ Certified copy is hereby WifsqFd. FIRE SPRINK ENERGY T-24
Z Z ❑ tified copy is filed it11 th. city inspection division.
MISC.- REFER TO ORD.
Q Ap Wean V ❑ N❑ V ❑ N❑
LL w CERTIFI CATIi 01'HSIiMP ION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU 5 COMPENSA'I'JON INSURANCE LG.CONTR, LIC.NO. PLG.
CL Z( This section need not be completed if the permit is for one TOTAL YE] N❑ Y E] [jN
hundred dollars(S 100)or less.)
U O 1 certify that in the purl in,a nce of the work I'ur which min per- TV. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner sn as to
L) become subject to the Workers'Compensation Laws of California.
i Hate Applicant - ALTER OR ADD TO MECH. 5.00 BUILDING s-D
} m NOTICE TO APPLICANT: ILIalter making this Ccdificare of Ex-
F-- ? emption,you should become shbject m the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of tire Labor Code. you must forthwith comply with
V such provisions or this perm;
erm i shall be deemed revoked. p AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 FEE 6/7 0
CONSTRUVION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE g
I hereby affirm that t)nere is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the perforemoce of the work for which this pe Unit is issued(Sec MICROFILM
3097,Ci,C.). i 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 adress ELECTRIC
I certify that I have nlad this application and state that the above VENTILATION FAN (SINGLE) 4.00
® information is currect+l agree to comply with all city and county PLUMBING
ordinances and state laws relating re
building construction, and BOILER-COMPI3 H.P.or 100,000B.T.U.) 6.00
herby authorize representatives of this city to enter pan the BOILER-COMP(Over 100,000BTU)SEE FEESCH. MECHANICAL
above-mentioned property lot 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 CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
granting Of this permit a ECH.CONT LIC.NO, MECH.
TOTAL TOTAL / J
Sig Blore o A Contr 1
INSPECTOR COPY
I