9195 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PERMIT NUMBERGILDIPROJECTlDENTIFICATION APPLICATION & PERMIT
ADDRESS
919 5
ADOREss
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
R -
N NIS- bz�p {QZPLAN CHECK VALIDATION
QTY. ELECTRIC PERMIT FEE
-9 Av;z-57-6566
. CIO
COAMEA oRs� OUTLETS-SWITCHES-RECEP 10.00/1.00
Lie NO, LIGHTING FIXTURES 10.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
OR JPANFLS (OVER 200 AMP) 20.00
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
...HHESS ENG. Y- SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
TIP EMP:METER OR POLE INS. 20.00
ADDRESS ADDRESS r$ MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
00 LICENSED CONTRACTORS DECLARATION TEMP.POLE N.00 1� -/
'et U u I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
G w (commenting with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
Professions Code,and my license is in full force and effect.
0w License Class Lic.Number EJ El
co
Date Contractor
a y f BUILDING PERMIT
¢ ¢
OWNER-BUILDER DECLARATION
¢o u O INFORMATION
ca g H I hereby affirm that I um exempt from the Contractor's License MISC.- REFER TO ORD
rLLo ¢ Law for the followingreason.(Sec.7031,5.Business and Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
Code:Any city or county which regtGresa permit townstnmt,alteq r?v
a, Q p improve,demolish,Or repair any structure,prior to its issuance,also ELEC.CONTR. LICNOELEC. '
G T requires the applicant for such permit to file a signed statement that TOTAL
u w he is licensed pursuant to the provisions of tire PERMIT TO e Contractor's License 1<�-V w
i Law(Chapter 9(commeneing with Section 7000)of Division 3 ofthe
5i o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE - AC�M/
¢ H o the basis for the alleged exemption.Any violation ofSecfhon 7031,5 - STORIES ' TYPE CONSTR.
by any applicant for a permit subjects We applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(8500).):
O 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 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 Contractor's License Law does not apply to an owner of
property who builds or Improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 50,FT.FLOOR AREA TOTAL ACREAGE
himselfor through his Own employees.Provided that such improve-
ments are not intended or offered For SIL.If,however,tie building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PS Omer
prove for purpose of sale). INDUSTRIAL WASTE INTER. 3000
❑ I,as owner of the property,am exclusively contracting with ❑ 0 ❑ ❑ ❑
liccnscd contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 - ASSESSORS PARCEL NO.
and Professions Coda:The Contractor's License Law does not apply
to at)owner of property who builds or improves thereon,andwho LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for Such projects with it contractums)licensed pursuant to
tire Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL No.
Cl I am exempt under Sec. ,B.&PL.for this WATER HEATER W/VENT 6.00
ree
-�
Ow nc " Date WATER SYSTEM 5.00 ACODATE ACC.FILE NO.
ti fWOFtKF 2S'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm hot 1 have a"Hificme of consent to sell'ricst re,
or a certificate of .,kers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab C.).
Policy N.. (,.,,,puny
O O Certified copy is hereby fumished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with the city inspection division.
O . Applicant MISC- REFER TO ORD. YE] IN Y ❑ IN
y CF-RT IIICATIi OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.UA.
W >_ COMPENSATION INSURANCE PLG.CONTR. LIC,No. PLG,
d O (This section need not be completed if the permit is for one TOTAL Y N Y N
0 Z hundred dollars IS 100)or less I
U O 1 certify that in the performance of the work fill which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
W U mit is issued,1 shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
ED Date Applicant BUILDING
} tan NOTICE TO APPLICANT': If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00 (-
F2 en,ption,you should become subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK
or visions of the Labor Code, you must forthwith comply with FEE
CJ such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO JOSMCF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 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 issued(Sec. MICROFILM
3097,CN.CJ. 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 Address ELECTRIC
I certify that l 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-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authoriLe representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agme to save, indemnify and keep li,mrlleas the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of tire
f[his mit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
g an[ hacfor [
INSPECTOR COPY
' I