7286 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
'LD
LDING
APPLICATION & PERMIT
AOORE55 �D
BUILDING - ELECTRICAL-PLUMBING -MECHANICAL 7286
PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
• %-o s3 3
CONTRACTORS
NAME OUTLETS-SWITCHES-RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 5.00 DATE OF APPLICATION
AHCHITECT SIGNS 6,00 PLAN CHECK FEE P.C.NO,
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
moo ESS OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
I ZIP TEMP.METER OR POLE INS. 15.00
APPLICANT
AmIlis EmPPLICA MOTORS SEE FEE SCH.
{ e 0
SERVICE CHANGE 1 .00 /
s� d�
F
00 + LICENSED C'ONT'RACTORS DECLARA'I'[ON
M o u 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
to rt
to with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F N z Professions Code,and my license is in full force and effect ❑ ❑ ❑ -
z 0 m - License Class Lic.Number-
2 z 0 Dam Contractor
¢ m E BUILDING PERMIT
¢ ¢O OWNER-BUILDER DECLARATION INFORMATION
E
N 1 hereby affirm that I am exempt from the Contractor's License MISE.- REFER TO ORD
VALUATION
.F LL o j Law for the folluwum rears,...(Sec.7031.5,Basin ess and Professions PERMIT ISSUANCE 8.00
Code:Any city or county which re9uiresa permit toconstrucn,they.
¢ ¢ zO improve,demolish,or repair any structure,prior to its issuance.cloy ELED.CONTR. LIC.NO. ELEC.
- 0¢ rttluires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
u w m Vy he is licensed pursuant to the provisions of the Contractor's License
z s- Law(Chapter 9(commencing with Section 7000)of Division 3 offlic 01
F 4 0 liusiness and Professions Code)or that he is exempt therefrom mail QTY. PLUMBING PERMIT FEE
¢ I- m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant loo civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more Dan five hundred dollars(S5000.):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 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. 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thercin,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve
-
TrentsarenutintendedoroUeredforstale.If,however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 4.00
ur improvement is sold within one year of completion,the owner GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have We burden of proving that he did not build or im-
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 2000
❑ 1,as owner of the property,am exclusively contracting with . ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor:'License Law does not apply '
to tin owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractions)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
ti ❑ am exempt under Scc.-,BAP.0 for this / WATER HEATER W/VENT 4.00
Owner D' a WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-insure, ZONING
or a certificate it Worker,'Compensation Insurance,or a aalifieA ENG.SITE NO.
copy thereof(See.3800,Lab C.T
Policy No. Company
0 ❑ Certified copy is hereby famished. FIRE SPRINK ENERGY T 24
z Z ❑ Certified copy is filed with the city inspection division.
Q Applicant MISE.- REFER TO ORD. Y N❑ Y ❑ N❑
jr W Cl,R1 I F KATE 01'Ii X EM PT ION PROM WORKERS' PERMIT ISSUANCE 6.00 - FLOOD-ZONE
LU > COMPENSATION INSURANCE PLG.CONTR. LAID.NO. PLG.
0. Z ('Phis section need not be Completed if the Permit is for one TOTAL - V E] NEI V E] NEI
hundred dollars($100)or less.)
U 0 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL l- mil is issued,I shall not employ any person in any manner so as to
O w become subject to the Workers'Compensation Laws of California. BUILDING
a Dal° Applicant ALTER OR ADD TO MECH. 4.00
} N NOTICE TO AI'1'LICAN'I': If,after making this Certificate of lix-
♦- ? emptiun,you should become subject to thCompensation APPLIANCE e Workers'Co - 4.00 PLAN CHECK
provisions of the Ubor Code, you must forthwith comply wills y FEE
U such provisions or this permit shall be deemed revoked.. AIR HANDLING UNIT(TO 10=CF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
[tic performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00 '
Lender's Name H EATI NG UN IT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
1 certify that I have read this application and stale than the above VENTILATION FAN (SINGLE) 3,00
i formation 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.) 4.00
hereby authoriec representatives of this city to enter upon the /
abuse-mentioned property for inspection purposes. BOILER-COMP (Over 100.000 BTU)SEE FEE SCH. MECHANICAL /
(We) agree to save, indemnify and keep harmless the City of misc.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expanses which PERMIT ISSUANCE - 3.00 CONST.TAX
in any :accrue against said City in consequence of the
gran n• f r MECH.CONT. LIG NO. MECH.
I.A.
�S TOTAL TOTAL
m u plica../Cunnractor Date
INSPECTOR COPY