9127 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING �U�y�� APPLICATION & PERMIT �� ��
ADDRESS
BUILDING -ELECTRICAL-PLUMBING -MECHANICAL
1 OWNERrc
PLAN CHECK VALIDATION ,
NAME CITY. ELECTRIC PERMIT FEE (//,J,RC, '.`
"onPHONE Ke (s(s _5 w/L
CONT AC R y
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00 IT ^'O'f�42� Jh �
T LIC.No. LIGHTING FIXTURES 10.0011.00 S'r1
APPLIANCES-RESIDENTIAL 4.00 r~I
noon CSS O 1 5�ayyI
-
PHONE PANELS 10.00 4-/S
DATE OF AVPLCCA'110N
AR rtEC PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.No. SIGNS TRANS. 3.00
ADDRESS E"c' SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE'SCH.
ADDRESS
SERVICE CHANGE 20.00 VV
00 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
¢ u u I hereby aflirm that I am licensed Ruder provisions of Chapter 9 ISSUANCE DATE
Q
n z w Commencing with Section 7000)of Division 3 of the Business and
BLDG. ELECT. PLG. MECH.
H w i Professions Code,and my license is in full force and effect ❑ ❑ O ❑
Licehu Class_ - Lic.Numbe
9 w r Date Contractor
Ara s - BUILDING PERMIT
¢ ¢ OWNER-BUILDFR DECLARATION
¢ w ID - INFORMATION
w
; Ii I hereby ultirn that I am exempors
t from the Contract ' License MISC.- REFER TO ORD
.. oa Law for the following reason.(Sec.7031.5.Businessund Professions PERMIT ISSUANCE 10.00 VALUATION g/FT.
Code:Anycity orcounly which requires a permit to construct,alteq
¢ m > improve,demolish,or repair an structure,prior to its issuance,also ELEC.CONTFL LIC.NO.
ce st Q r P P" Y p ELEC.
0 ¢ requires the applicant for such permit t0 file a signed Statement that TOTAL PERMIT TO
n w m o he is licensed pursuant to the provisions of the Contractors �w License "/0Va-
Law(Chapter 9(co nuncncing with Section 70001 of Division 3 of the ('�.�.
< Business and Pro@sslons Code)Or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE S/Z e A Q U QtL
¢ r o the basis for the alleged exemption.Any violation of5ection 7031.5 STORIES TYPE CONSTR.
an ;m by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars f$5001.):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP REB.UNITS
sole compensation,will do the work,and the structure is nm
intended or offered for sale (Sec. 7044, Business and ProfeSsiODIS DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code: The Contmetoi s License Law docs not apply 10 an owner of
property who builds Or improves thereon,and who does such work FIXTURES.'PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve.
meats are not intended or offered for sale.If,however,the 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
builder will have the burden of proving that he did not build or int- BUILDING USE
prove for purpose of sale.). 4 INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ 1,as owner of the property,am exclusively contracting with ElEl , El El El
licensed contractors to constru-t the project(Sec. 7044,bustles, LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS 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 contractor(s)licensed pursuant to SEWER-SAN V-STORM EA.200ft]10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ Iwo exempt under Sec. ,B.&P.C.Porthis WATER HEATER W/VENT - 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE Ace.FILE NO.
WORK ERS'COM PENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of emisent 10 self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
C
hercoff Sec�38�00,Lab.C.l.
oNo/company
O ❑ Ccdrd_ie o ix I;Xby(urnls FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy u filcA wtR .ith cDY inspecti 'vision.
OL Applicant MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N❑
y CERTIFICATE of EXEMPTION FROM1 RKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.L.C.
W 7 - COMPENSA'I'ION INSURANCE PLG.CONTR. LIC.NO. PLQ Y❑ NE] Y ❑ NE]Z (This section need not be completed if the permit is for one TOTAL
hundred billars(5100)or less,)
V O 1 I certify Dmt in the pc on,rnnance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,1 shall not employ awry person in any manner so us to
0 Ubecome subject to the Worker Compensation Laws of California. BUILDING
Ul
y Uate APPlicant ALTER OR ADD TO MECH. 5.00
} N NOTICE TO APPLICANT': IL alter making this Certificate of Ex.
F ? emption,you should become subject 10 the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply' with FEE
CJ such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION L17NDING AOI?NCY AIR HANDLING UNIT(OVER 10,000GEM.) 6.00 SEISMIC FEE
I hereby infirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the
p,, Iv C1. ace of the work for which this peMICROFILM
permit is issued(Sec. HEATING UNIT(TO 100,000 B:T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify 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 stale laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100p00BTU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs mid expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
grant in of this permit. �I. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
gn e o p Ica / o -Date
INSPECTOR COPY