9298 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LD1 NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT ��
AoIRES;
BUILDING LDING-ELECTRICAL-ICAL-PLUMBING-MECHANICAL
O PLAN CHECK VALIDATION
• NAME 4!S QTY. ELECTRIC PERMIT FEE
PJ(1 PHONE
HAMER crF?gfZTUTLETS-SWITCHES-RECEP 10.00/1.00
LIC,NO. LIGHTING FIXTURES 10.00/1.00
TRA ADDRESS oi99 PPLIANCES-RESIDENTIAL 4.00
PH NE "T PANELS IO.00 DATE OF APPLICATION
OR HIr PANELS (OVER 200 AMP) 20.00 PLANCHECKFEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
N¢ SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
-lrly ISI
ZIP TEMP. METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLAS AIRISN TEMP.POLE 30.00
a i w 1 hereby affirm that I am licensed under provisions of Chapter 9 / ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and
G G c BLD .
F m i Professions COLIC,r,aril my licensr, rn full force and effect. ELECT. PLG. MECH.
,,
z 0 w - License CIOz,; �.�.�Lic.Number-{_2�.(�.(Cdp - 0' 0
o y r Date Contractor l„F �-.S-fW
stu r sY� UILDI NG PERMIT
0 re <u U OWNER-BUILDER DECLARATION INFORMATION
X
g LL I_ 1 hereby affirm that I um exempt from the Contractor's License MISC.- REFER TO ORD
LL 0 sr Law for the following reason.(Sec.7031.5,BOSlneSsand Professions VALUATION $/FT.
_ PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter, //��//��
O improve,demolish,or repair any structure,prior 10 its issuance,also ELEC.CONTR. LIC.NO. ELEC. Q(/E/
25 0 LL requires the applicant for such permit to file a signed statement that TOTAL
w m m he is licensed pursuant to the provisions of the Contractor's License PERMIT TO \
Fz > Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
E i o Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
X Ha the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
dam _ by any applicant for a permit subjects the applicant to a civil penulty ALTER-DRAIN -WATER IEA.) 5.00
of not more titan five hundred dollurs(S500)J:
O 1,as owner of the property.or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 Oce.GROUP RES.UNITS
their sole compensation,will do the work,and fit,structure Is not - Y
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 {.%
Code:'flee Contractor's License law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTALACREAGE
himselfor through his own employees,provided that such improve-
arentsarenetimendedoroffered for sale.If,however,the building GAS-EA.SYSTEM-1 1 NC.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 am- BUILDING USE
RE IND CO PB Other
pane]or s owpurpose of sale.). INDUSTRIAL'WASTE INTER. 30.00 ❑ ❑ E]
❑ d as owner of the property,he exclusively contracting with
andPro contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- I INC 5 V.B. 6.00 a55ES5 s P CEL N0.
and Professions Code:The Contractor's License law docs not apply
to in owner of property who builds tr improves rased pursuant
who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts ct such projects with a contrucmrl sl licensed pursuant to
the Contractor's License Luw, SEWER-SAN ITAR V-STORM EA.200ft/10.00 / TRACT NO. PARCEL NO.
❑. lam exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.OATE ACG FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
i copy therroffSee.3800,Ult-1).
1 sy-Islo Company
O CrrtitieJ opy is COi yQ d. FIRE SPRINK ENERGY T-24
Z 2 ❑ Certified 'Il it d 1 ci 'Ism ion division.
O Applicant / r /c MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ NF]
� y Cs TI FICATE OF EXEMPTION FROM WORK ERSx PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL 0( This section need not be completed if the permit is for one TOTAL Y N Y N�
hmhdred dollars(S 100)or(CSO
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in any manner so as to
O L) become subject to the Workers'Compensalion Laws of California.
Date Applicant BUILDING15
} C. NOTICE TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00 7
F z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10OW C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.P.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,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 1 have read this application and stair that the above VENTILATION FAN (SINGLE) 4.00
information is correct, I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.1 6.00 PLUMBING
ordinances and state laws relating to hailding roast ruction, :coil
hereby amhorlra rrpfewntatives of this city to ewer upon the BOILER-COMP(Ove.100,000 BTU)SEE FEE SCH. MECHANICAL
r above-mentioned property for inspection purposes.
l "? 'gree to save, indemnify and keep hornless the City of MISC.- REFER TO ORD. I
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in a anew against sa�tl City in consequence of the
granting w -n ti MECH.CONT, LIC.NO. MECH.
TOTAL TOTAL UU
n re A fi inert (
Date _
INSPECTOR COPY "'