8195 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
13U LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
° - BUILDING- ELECTRICAL-PLUMBING-MECHANICAL I g5
OWNER'S PLAN CHECK VALIDATION
NAME
OO.�dI PSioNE DTV. ELECTRIC PERMIT FEE
•� NAAMERacioRs OUTLETS-SWITCHES-RECEP 10.00/1.00
D. y
a LIGHTING FIXTURES. 10.00/1.00
r.D ipACTORs _APPLIANCES-RESIDENTIAL 4.00
ADDRESS 2 Q y
NE O PANELS 10.00
(4/ I. �Jp DATE OF APPLICATION
ORRcwiECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.N0.
ENGINEER
uc.NO. SIGNS TRANS. 3.00
ADDRESS ENc. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP fTEMP.METER OR POLE INS. 20.00
APPLICANT 5 MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
w o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
yw (commencing with Section 7000)of Division 3 of the Business and
4 A BLDG. ELECT. PLG. MECH,
r y i Professions Code,and my license is in full force.I[�d effect.
z 0 to Llcensc Cla.cs Li,Nucha, -T 4•C/e7.214
o m �>; Date ['�.$Z[`_Contractor_ .DAA
a x f BUILDING PERMIT
0 6 D OWNER-BUILDER DECLARATION INFORMATION
E
3 LL Iw I.hereby affirm that I am exempt front the Contractor's License MISC.- REFER TO ORD
VALUATION $/FT.
r LL o J Law for the following reason.(Sac.7031.5.Business and Professions PERMIT ISSUANCE 10.00
Code:An,city or coo my which structure P prior
toconsuance,lmq ELEC.CONTR. LIC.NO.
ac improve,demolish,or repair any structure,prior to its issuance,also ELEC.
0 ec requires the applicant lot such permit to file a signed sWtnnent that TOTAL PERMIT TO
ca w he is licensed pursuant to the provisions of the Contractor's License
r
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
4 Business and Profcssious Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
ti o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
A by any applicant for u permit subjects 0m applicant to civil penally
of not more than five hundred dollars(S500).): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5,.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or Improves thereon,and who does Such Mork FIXTURES-PER TRAP 5.00 50,FT.FLOOR AREA TOTAL ACREAGE
himself re through his own fmredfors• le.11,ho thus such improv✓
hients mself o nhrougot his oroffaredformleovided that however.ilia building GAS-EA.SV$TEM-11NC.40UTLETS 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 im- BUILDING USE
Prove for purpose of sale). INDUSTRIAL WASTE INTER30.00 RES IND CON PB Omer
❑ I,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. 6.00 ASSESSORS PARCEL NO.
and Professions Coda:"1he Contractor's License Law docs not apply
to an owner s'1'property who builds or improves thereon.and who LAWN SPRINKLERS-OV ER 5(EA.) 1.00
contracts for such projects with a conlmetor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lura exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Data WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have.certificate ofcunsern to self-insure.oZONING ENG.SITE N0.r a certificate of Workers'Compensation Insurance,or a cerci OeJ
�[ copy thereof(See.3800.Lab.C.f
J- Policy No. Compmry
O ❑ Certified copy is hereby fumished. FIRE SPRINK ENERGY T 24
Z_ Zr �
CC O 'Certified copy is filed with the city inspersion division. MISC.- REFER TO ORD.
P.b{lmanl Y ❑ NNE] Y ❑ NE]
PERMIT ISSUANCE _10.00
CCCERTIFICATI>OF EXEMPTION PROM WORKERS' - FLOOD ZONE A.L.u.c.
LU > COMPEN5AT10N INSURANCE PLG.CONTR. LIC.NO. PLG.
d (This section need nbe completed if the permit is for one TOTAL Y
ot ❑ NE) Y E3 IN E]
Z hundred dollars(if 00)rules'.)
U O I certify that in the performance of the work for which this Par- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL t- mit is issued,I shall not employ any person in any manner so as to
O become subject to the Workers'Compensation Laws of California.
a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE TO APPLICANT: If,after making this Certificate of E.-
F ? emption,you should become subject to ilia Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Lahor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which Th is Permit is ism ed(Sea MICROFILM
3097,Civ.C.). H EATING UN IT(TO 100,000 B.T.U.) 8.00
Lenders Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Landau's Name ELECTRIC
1 certify that I have read this application andstate that the above VENTI LATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING 0
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000B.T.U.) 6.00 U
hereby authorize representatives ins of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
hereby authorize
properly fnrinsp of (h purposes.
(We) agree to save, indemnify and keep harmless ilia City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may i any way accrue against Said City in consequence of the PERMIT ISSUANCE 10.00
Bran in of chis perm I MECH.CONT. LIC.NO. MECH.
11 TOTAL TOTAL
Signa t lice actor Due I
INSPECTOR COPY