7023 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
, BUILDING PROJECT I IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS G G
lkb NG -ELECTRICAL-PLUMBING-MECHANICAL 7U23
OWNER' PLAN CHECK VALIDATION
NAME ' ELECTRIC PERMIT FEE
I hp• vnoN
NAME oRs UTLETS-SWITCHES-RECEP 5.00/1.00
NAME
mf h LIGHTING FIXTURES 5.00/1.00
ADD A *oRs PPLIANCES-RESIDENTIAL 4.00
ADDT
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.NO. ISIGNS TRANS. _ 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
woo LICENSED CON FRACTORS DECLARATION
I hereby affinity that I..I licensed under pHvbi.....of Chapter 9 ISSUANCE DATE
. N G w lann nu•nc ing with Seelion 7000)of Do,,CC,3 of the Buxinc"an BLDG. ELECT. PLG MECH.
F D z Professions Code,and Iny license is in full fur' c c ❑
'z o m- License Class Lic.Nu n.ber ❑ ❑
o r Date Contractor '
.Q m s J BUILDING E MIT
-¢ ¢ w ¢ \V :R- ILDI:R DECLARA O ' INFORMATION
A o A U MISC.- REFER TO ORD
w 3 P. H I hereby affirm that I am exempt from the Contractor's License VALUATION SIFT.
,HLLo¢ Law for the following reason. 7031.5.Business and Professions pERMIT ISSUANCE 6.00
to Code:Any city or county which Hyp fres a permit to construct,alley,
¢ 2 Q 2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. -
- 6 ra•quitts file applicant for 9ueh permit to fit...igned statement that TOTAL PERMIT TO
wm he is licensed pursuant 4)the provisions of file Contractor's License
H z i
Law(Chapter 9lcomnancing with Section 700(Hol Division 3 of the AL (j 6"
Business and Professions Code)or Him he is exempt tlmrefuln and OTY. PLUMBING PERMIT FEE
cera I lNasis for the alleged exemption.Any violatinn of Section 7031.5 STORIES TYPE CONSTR.
a3 $ by any applicant for a permit subjects the applicant to it civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
�1) 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,GOND. 4.00
Code:The Contractor's License Law does not apply to an owner of
Property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 sa FTFLOORAREA TOTALACREAGE
himself or through his own employees,provided that such improve-
.mnts are not intrndce or offered Cor sale.If,howevel.the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 4.00 _
+ or m ¢m
pement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
buiider will have the burden ofproving that hu did not build or im- RES IND CON PB ower
prove lir,purpose trolly.) INDUSTRIAL WASTE INTER. 20.00
❑ 1,as owner of the properly,am exclusively contracting with E] El ❑ ❑ El
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code- I'lie Contractor's License Law does not apply '
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS,OVER 5(EA.I 1.00
contracts for such projects with a contractoRs)licensed pursuant to
the Contractor:License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. B.&P.C,for this WATER HEATER W/VENT 4.00
reason
Owner Dale WATER SYSTEM 4.00 4 ACCDATEACC.FILE NO.
WORK ERS'COMPENSA NON DECLARA"I[ON WATER TREATING EQUIP. 4.00
I hereby affirmthat [ [love a certificate of consent to'ell-insure, ZONING ENO.SITE NO.
or a certificate of Workes'Compensation I a ce,n r' a rtifie
opyI -
folic
❑ r p Y ni cd FIRE SPRINK ENERGY T114
❑ Certi e Co is (-bled wit a 'ty 'n � u is MISC.- REFER TO ORD.
z ZO Applicant _ ❑ N❑ v ❑ IN E]
Hy PERMIT ISSUANCE 6.00 LOOT ZONE A.L.u.C.
X CIS ICA'I'RPESWIOTINS RAN WORKIikS'
W >_ need I...A be
INSURANCE the PLG.CONTR. LIC.NO. PLG. Y❑ N❑ Y❑ N❑
d flies action need not hu conmlcfed if the prnnif is for one TOTAL
L) Z hundied
cert dollars(5100)pe Ice.l
LL O I certify that h the (e employ
an of the work I'or which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mil is issuede 1 shall not employ any person in any manner so a,to
U become subject to the Worker,'Compensation Laws of California.
Q w BUILDING-
. Dat° ICANIa"I ALTER OR ADD TO MECH. 4.00 `,
F7 rn NOI'ICI'. you
APPLshout become
: IL after making this Workers'
Certificate sa Ex
F7 ? emption,vision you The L become subject to the W rthwii Ccomply with APPLIANCE 4.00 PLAN CHECK
Provisions io the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemeJ revoked. AIR HANDLING UNIT(TO 10,000OF.M.) 3.00
CONS I'ROC'(ION LENDING AGENCY AIR HANDLING UNIT(OVER 10p00C.F.M.) 5.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
309he 7,SCiv.C.)nce of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
1 certify that I have read this application and state that the above �V ENTILATION FAN (SINGLE) 3.00
• information is correct. I agree to comply with all city and county PLUMBING
orcin..", and state laws relating to building construction, and BOILER-COMP(3 H.P.or IO0,000B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
;E (Illy) agree to save, indemnify and'keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs aid expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way ace uc against said Ci[�y)"(�mseyuence of the
0[Ng oflhis per i WV/ CH.CONT. LIC.N0. MECH. D
T� TOTAL TOTAL
Si o A a t tRuto ate
+ INSPECTOR COPY