C9237 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT /1 ����
ADDR S2 MIIJ�
2y� BUILDING-ELECTRICAL-PLUBING -MECHANICAL
OWNER'S PLAN CHECK VALIDATION
'I NAME OTY. ELECTRIC PERMIT FEE
1 . r ONE
NOMEngcTORs OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO, LIGHTING FIXTURES 10.00/1.00
cory Cap S I PPLIANCES-RESIDENTIAL 4.00
ADDRESS ,
PHONF PANELS 10.00 DATE OF APPLICATION
OORRCHrtECT PANELS (OVER 200 AMP) 20.00 '� PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No, SIGNS TRANS. 3.00
ARC".OR ENG. SPECIAL CIRCUIT 5.0Q PERMIT
�VALIDATION
ADDRESS- ZIP EMP.METER OR POLE INS. 20.00 PA
APPLICANT'S MOTORS SEE FEE SCH.
ADDRESS !AUG
SERVICE CHANGE 20.00 L !AUG 2
19,.5
Doo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
/ y U�s`
a u u 1 hereby ,wit that I am licensed underp 3 of
ofChapterd n L(fiELECT.0 ` ATE.,.
y < (convneneing with Section 7000)of Division 3 of the Business and BLD ELECT. PCO" MEGH. "
H w z Professions Code,and my license is in full farce and effect. (' ,.A
a 0 m W License Class Lic.Number - � e ❑a
U.Ic Contractor
a y E
¢ a OWNER-BUILDER DECLARATION BUILDING PERMIT
d a a u INFORMATION
w 3 u y 1 hereby affirm that I am exempt Gam the Contractor's Livens, MISC. REFER TO ORD
-
u. 0a Law for the followingreasOn.ISec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT:
ECode:Any city orcounty which requiresu permit reconstruct,alter,
E
¢ ¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
d W m¢ requires the applicant for such permit t0 file a signed statement that TOTAL PERMIT TO
he is licensed pursuant to the prmisions of the Contractor's License
FiQ Law(Chapter 9(commeneing with Seen..7000)ot'Division 3ofthe
Business and Professions Code)or that hu is exempt therefrom and OTY. PLUMBING PERMIT FEE 1 (/
(C o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TVP ONSTR.
es.Luw 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).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 oee.GROUP RES.UNITS
their wile compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:'I'Im Contractor's License Law does 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
^� himself or through his own employees, le.If,however,that such improve-
ments are not rota his or employer,pro L ed thatsu he building GAS-EA.SYSTEM-1 1NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not . - .
build or im- BUILDING USE
prove for purpose of salt.). `R,. INDUSTRIAL WASTE INTER. 30.00 IND CON PB Omer
1; ❑ I,m owner of the property,am excltucively .ntractiT,with
licensed contractors to construct the project(Sea 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00ASSESSORS 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 comractorts)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor' License Law. TRACT NO. PARCEL NO.
❑ I;un exempt under Sec. ,B.&P.C.forthis
reason ', WATER HEATER W/VENT 6.00
/ Owner Date � WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
W :RS'COMP'( S TION DECLARATION /'uJ WATER TREATING EQUIP. 5.00
I hereby Grm than ha • certifcateofconsent In f-insure.
or a certificate of Workers'Compensation Insurance,ora certified ZONING ENG.SITE NO.
copy thcnv((Scc.3800,Lab.C.).
Policy No. Cont pany #
0 ❑ Certified copy is hereby famished FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is fled with the city inspection division,
MISC.- REFER TO ORD.
0 Applicant Y O NJ:) Y ❑ N[]
~ va PERMIT ISSUANCE 10.00
LU ClikTll'ICCOMOPSAIJONION FROM WOkKIikS' FLOOD ZONE A.L.U.C.
W > ,:' COh1P1iNSA1'ION INSURANCE PLG.CONTR. LIC.No.CL PLT.
Z This section need not be completed if.the permit is for one TOTAL YE] N� Y N�
hundred dollars IS 100)ur,less.)
U O I certify that to the performance of the work for which(his per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
0 w become subject to the Worked become Laws of CTlil'omfa.
CL Dute Applicant ALTER OR ADD TO MECH. 5.00 BUILDING O
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
Z_ emption,you should become subject to the Workers'Compenmtion APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or(his permmn
it shall be dced revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE
I torehy affirm that (here is a construction Iuuling agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of(he work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.y HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(O VER 100,000B.T.U.)9.50 ELECTRIC
Lender's Address
I certity that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct, I agree'to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMPI3 H.P.Dr 100,000 B.T.U.1 6.00 Y
hereby authorize representatives of this city to enter upon the BOILER (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-menlioneJ property for inspection purposes.
(We) agree ro save, indemnify and keep harmless the City of MISC.- REFER TO ORD. F
Cupertino against Iiahi'IIT it IT ts, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX }
may in any way Terra again t said City in consequence of the )
grantingoh tis permit MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
o O tree or fc 1
INSPECTOR COPY