9192 T
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 ISI
ADDRESS I' A
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL VE
d r?
OWNERS PLAN CHECK VALIDATION
.0 192
NAME• ONE QTY. ELECTRIC PERMIT FEE
NON s UTLETS-SWITCHES-RECEP 10.00/1.00 c
L, C� LIGHTING FIXTURES 10.00/1.00
'ONTN APPLIANCES-RESIDENTIAL 4.00
aoo
PANELS 10.00 DATE OF APPLICATION
ROH PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO, SIGNS TRANS. 3.00
ADDRESS ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
ADDRESS ^ [-
AMOTORS SEE FEE SCH..
ADDRESS
SERVICE CHANGE 20.00 q y
o o LICENSED ON'IRACTORS DECLARATION TEMP.POLE 30.00 /pt /
1 ¢u eH0 1 hereby afli t lisens under p Ise s n(Chapler 9 ISSUANCE OATE
f y rt a (conunencin I S n�00 Divi ' le Business and BLDG. ELECT. PLG. MECH.
H % I'rofcxsioh y tic r' c w d cf@c
o 0 m.� Licens ie alter El E
E3 ❑
Da Co
Ha m f � BUILDING PERMIT
¢ ¢O OWNER-BUILDER DECLARATION INFORMATION
w3: LL H I hereby affirm that I am exempt Goa the Contractor's License MISC.- REFER TO ORD
LOv, Law for the following reason. 7031.5,Business and Professions pERMIT ISSUANCE 10.00 VALUATION 9/FT.
Code:Any city or county which requiresa permit toconstrom alter.
¢¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. �/ V
va
3 Oo M requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w m m he is licensed pursuant to the provisions of the Contractors License
H z < Law(Chapter 9(commencing with Section 70000dDlvision 3 ofthe
4 O liusimess and Professions Code)ser that he is exempt t erefrom and OTY. PLUMBING PERMIT FEE .b-L L
(C H ro Ila basis far file alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
Ate _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
,of Hol nurre than live hundmd dollars(5500).):
Cl I,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00 1 OCC.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 an owner of
property who builds or improves thereon,and who does such work F I XTUR ES-PER TRAP 5.00 50:FT.FLOOR AREA TOTAL ACREAGE
hinhself or through his own employees,provided that such improve-
mentsare not intended oroffered forsale.If,however,the building GAS-EA.SYSTEM-I INCA OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM-OVER 4 IEA) 200
builder will have the burden of proving that he did not build or im- - . . .
BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER30.00 RES IND CON PB Omer
❑ I,as owner of the properly',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 dues not apply
to an owner of property who builds or improves thereon,and who LAWN SPR IN KLERS-OVER 5 (EA.) 1.00
Contracts]or such projects with a contractor(,)licensed pursuant m SEWER-SAN V-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ I am exempt under See---B&P,C for this WATER HEATER W/VENT 6.00 `
reason
Owner Date WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO.
WORKERS'COMPENSAI'[ON DECLARA WATER TREATING EQUIP. 5.00
1 hereby affirm h ceeE ifs of tto self-insure. -
or a certificate its m urance,or a cernfieJ ZONING ENG.SITE NO.
- copy there 8 .0 .
folic
0 ❑ C -m or is
z z ❑ Cent py s ed�s he section division. FIRE SPRINK ENERGY 24
O" Anplic' MISC.- REFER TO ORD. y❑ N❑ Y ❑. N❑
a :R ' - Ii IF EX!hIPTIO rV ! W RC RS: PERMIT ISSUANCE 10.00 FLOOD ZONE AL.UC.
LU 5 COM
EN
CIL O (This section need Inot bel compllel dlif the pencil is for one PLG.CONTR. LIC.NO. TOTAL V❑ N❑ Y ❑ N
Z) z ❑
hundmd AOIIuIs(81001 or less.)
U O 1 certify that in the performance of the work 1..which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,1 shall not employ any person in any manner so as to
Q ) become Subject to the Workers'Compensal ion Laws of California.
LU Date Applicant BUILDING
n ppcanALTER OR ADD TO MECH. 5.00 n
} m NOTICE TO APPLICANT: if,atter making this Certificate sa Ex-
F ? em vision you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions io the Labor Code, you mus( drevoke comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,OODCF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE STj
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work I'or which this pcnc it is issued(Sec. MICROFILM
3097.Civ C.). HEATING UNIT (TO 100,0008.T.U.) 8.00
Lender's HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's
Name
ELECTRIC
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
infonnolion is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COUP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorise representatives of this city to enter upon the
above mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)BEE FEE SCH. MECHANICAL
(We) agree to sa indemnify and keep harmless the Cil of MISC.- REFER TO ORD.
Cupertino agai ( ,bilin dghanls, c s 'nd exp w nth PERMIT ISSUANCE 10.00 CONST.TAX
may in an7 aocr[;, ainst (aM h con enc the
graHlin perp ( MECH.CONT. LIC.NO. MECN.
TOTAL TOTAL
INSPECTOR COPY