9333 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LD ING PROJECT I DENTIF I CATION PERMIT NUMBER
ADDRESs> 99 9 S s APPLICATION & PERMIT ���
UI LDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME Q/? eh Pee OTY. ELECTRIC PERMIT FEE
ONE
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO. LIGHTING FIXTURES 10.00/1.00
ADDRESS oR's PPLIANCES-RESIDENTIAL 4.00
CONTRA
PHONE - PANELS 10,00 DATE OF APPLICATION
ORRCHrtELi PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C,NO.
ENGINEER
sac.No. SIGNS TRANS. 3.00
ARCH OR
ENG, SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. f 20.00
APPLICANTS
ADDRESSMOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
D 02 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a u I hereby aftion that 1 am licensed under provisimn of Clmpter') ISSUANCE DATE.
H i A,y
Q (commencing with Section 7000)of Division 3 of the Business and
BLDG' ELECT. PLG.
H th z Professions Code,and my license is in full force and effect �' ❑ ❑
Z, o m - License Class Lie.Number
9 y w Dolc Contractor
`a Y BUILDING PERM(
¢ o n U OWNER-BUILDER DECLARATION INFORMATIO
X
; LL F I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
LL o¢ Law for the following reason.(Sec.7031.5,Businessand Professions VALUATION S/FT.
- � Code:An cit or count which requires PERMIT ISSUANCE 10.00
Any y y q permit construct.alter,
at O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
- LZ Er requires the applicant for such permit to file a signed statement that TOTAL P By
TO
K
m he is licensed pursuant to the provisions of the Contractor's License
Fir Law(Chapter 9(emnmencingwill,Section 7000)of Division 3 of the
4 o Itusincss and I'mlcssions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
F o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
d3ra by;my applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($5001)
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compenulion,will do the work,and the structure is not
intended or offered for sale(Sec. 7144, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who docs such work F IXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such im
« prove-
menare not intended or offered for sale If.however,the building GAS-EA.SYSTEM-l1NC.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 fm. BUILDING USE
pro for purpose of RES IND CO PB Other
s I,as owner of the propetly,am exclusively contracting with
INDUSTRIAL WASTE INTER. 30.00
tic •d contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSO S RCEL NO.
am Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or ifnproves thereon?and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts for such projects with a contractnr(M licensed pursuant m SEWER-SANITARY-STORM EA.200ft/10.00
N11by
License Law. TRACT NO. PARCEL NO.
exempt unl•r Sce. e.&P.C_for ibis WATER HEATER W/VENT 6.00
- _ Dae WATER SYSTEM 5,00 ACC.DATE ACC.FILE NO.
ERS'COMP- ION DIE TION TION dd WATER TREATING EQUIP. 5.00
m that I have a certificate of cdn. nl to w ain.vuq
or a ecrlificate of Workers'Compensation Insurmme,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lb.C.L
Policy No. Company
O ❑ Certified copy ishereby famished. FIRE SPRINK ENERGY T 24
ZZ ❑ Certified copy is Tied with the city inspection division. MISC.- REFER TO ORD.
ZY ❑ N� Y ❑ NE]
rn PERMIT ISSUANCE 10.00
fr - •CIi R'I'IF'-IGONi ENSAIMPTINSURA b1WORKERS' FLOOD ZONE q.L.u.C.
W > COMPENSATION INSURANCE PLG.CONTE. sac.NO. PLG.
CL 0 (This Section teed not be completed if the permit is for one TOTAL Y❑ NE] Y❑ N
hundred dollars IS 100)or less.)
/ U O 1 certify that ire the performance of tire work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mil is issued,1 shall not employ any person in any manner"'as to
O L) become subject to the Workers'Compensation Laws of California.
O- Dale Applicant ALTER,OR ADD TO MECH. 5.00 BUILDING
} rn N'O'TICE TO APPLICANT': If,after making this Certificate of Ile
F. 2 emplion,you should become subject to the Workers Compensation 7 APPLIANCE 5.00 PI AN CHECK
provisions of the labor Code, you most forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MOC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IQOOOC.F.M.) 6.00 / SEISMIC FEE
I hereby affirm that there is a construction lending agency kn EXHAUST HOOD (WITH DUCT) 5.00
the perlimnance o1'the work lin which this permit is issued(Sec. MICROFILM
3097,Civ.C.). 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 I have read this application and state Ill"the above VENTILATION FAN (SINGLE) 4.00
• ml'onnaliun n correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building 1 city and . and
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above lnedioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless 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 Cip• in consequence of the
granting. this permit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
ignalure of APP so c
cant/Clb
are
INSPECTOR COPY