C9162 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
ACROWJ'WINGSE _ APPLICATION & PERMIT ��
HOlss
UILDING - ELECTRICAL-PLUMBING-MECHANICAL
E 'S L CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
ONE/ C
NAME C Rs OUTLETS-SWITCHES-RECEP 10.00/1.00
/ Lm.No. LIGHTING FIXTURES 10.00/1.00
I ENTRAcroa's APPLIANCES-RESIDENTIAL 4.00
CO T A
NE PANELS 10.00 DATE OF APPLICATION
A IT PANELS 200 AMP) 20,00 - PLAN CHECK FEE P.C.
OR NO.
ENGINEE
uc. SIGNS TRANS. 3.00
ADDRESS a SPECIAL CIRCUIT 5.00 _ PERMIT VALIDATION MI
2,P EMP. METER OR POLE INS. 20.00 , PAID
APRLICAs MOTORS SEE FEE SCH.
AODREss SERVICE CHANGE 20.00 IJUN 211985
00 o LICENS17D CONTRACTORS DECLARATION TEMP.POLE 30.00 /1+y �{ Ilflpr{Irt
¢ w Y p p {gitU APCC"d-AT no
u u I hereb affirm that I am licensed under rovisions o'Cha ter 9
a z
(commencing with Section 70001 of Division 3 of the Business and
¢ vaiBLDG. ELECT. PLG. MECH.
F H z Professions Code,antl my license is in full force and effect. ❑ E3z o m - License Chess Li,Number
o w - u Date Contractor
a y M < BUILDING PERMIT
¢ ¢ ¢ OWNBk-BUILDER DECLARATION
¢ u, u INFORMATION
w 3 u y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
LL o a Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
� - Code:Any city orcounly which requires a permit to construct,alter,
, Q Q 2D improve,demolish,Dr repair any structure,prior to Its Issuance-also ELEC.CONTE. LIC.NO, ELEC.
wO requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO -
he is licensed pursuant to the provisions of the Contractor's License
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r o
the basis for the alleged exemption.Any violation of Section 7031.5 RI P CONSTR.
a3w 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(S500).):
❑ I,as owner of the property,or my employees with wagesas BACK FLOW PROTECT. DEVICE 4.00 C . OUP E UNITS
'
their sole compensation,will do the work,and the structure is not
- intended or offered for s,I, (See 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code'. The Contractor's License Law does not apply to an owner el
property who builds or improves thereon,and who does Such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTALACREAGE
• himself or through his own employees,provided that such inlprove-
meats are riot intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
hui de will have the burden of proving that he did not build or inl-
pm or purpose of sale.). RE IND CON ,PB Otuer
I,as owner of the property,am,xdusrvcly contr4I ngwith INDUSTRIAL WASTE INTER. 30.00 A, ❑ ;El ❑
tic s contractors m construct the project[Sen 7044,Rosiness LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
a A Professions Code The Contractor's License Law docs not apply 1
r an owner of property wl o builds or 1 pr ves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 �r
contracts for curb pales ith a c t- licenmd pursuant to ry
the GOntfaelnls Lie, -aw. / SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. ':`PARCEL NO.
-hmexem crSec ,B.&P.C..for tires WATER HEATER W/VENT 6.00 -
reason
Owner Date - 5 WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
v1ORKERS'C PENSATION DECLARAT ION WATER TREATING EQUIP. 5.00
1 hereby affirm thai I have a evilificale of consent to self-ensure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec 3800,Lab.C.).
Policy No. Company
Q ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certilled copy is filed with Bre my inspection division.
p Applicant MISC.- REFER TO ORD. Y N� YE] NE]
CCN CERTIFICATE OF EXEMPT ION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.UC.
LU > COMPENSATION INSURANCE PLG.CONTE. LIC.N0, PLG.
CL a This"section eed not be completed if the permit is for one TOTAL Y[:] N❑ Y E] N
hundred dollars IS 100)nrless.)
U O 1 certify that in the performance of the work for which tris per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued, I shall not employ any person in any manner so as to
0w heceme Subject to the Worker'Compensation Laws of California.
y Dat, Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE TO APPLICANT'. If,after nmking this Certificate of Ex-
Z emption,you should become subject to the Workers'Compaaation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.EM.) 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 isued(Sea MICROFILM
3097,Ci,C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's No HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
ipl ormation is correct, I agree to comply with all city and county PLUMBING
ordinances and state laws elating to huOdirg construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this c to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property Cor inspection pl oses-
(We) in. to se, ind ni an k IF harmless the City of MISC.- REFER TO ORD.
Cupertino again '.bilin ,jn e s, sts and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any accrl` aualn 1 d y in consequence of the
granting of .permit. MECH.CONT. LIC.NO. MECH,
TOTAL TOTAL
at m/ at c or at
INSPECTOR COPY