9122 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
ADDG APPLICATION & PERMIT J ��
ADDRESS
�I BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
_`!
IEFS PLAN CHECK VALIDATION
1' NAME OTY. ELECTRIC PERMIT FEE
II h-15
t--'I ✓'�r� P orvE
NAME"A TOR's UTLETS-SWITCHES-RECEP 10.00/1.00
T
ADDRESS LIGHTING FIXTURES 10.00/1.00
OR,
"S PPLIANCES-RESIDENTIAL 4.00
yCADDRESS
C�, /� ,- PHONE PANELS 10,00 DATE OF APPLICATION
R
OR Is,
PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS Ervc. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. 20.00
APPLICANT SNs MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 G
w00 LICENSED CONTRACTORS DECLARA'T'ION TEMP.POLE 30.00
Q U I hereby affirm That I mn licensed under provisions of Chapter 9 ISSUANCE DATE 1
w G w (commencing with Seel inn 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H mz I''of essunit,Code,und'my license is in full force and effect.
o 0 va o .License Class Lic.Number El
El 15k
,A H w� Uute�: 43-s s� Cont tactor -� .
¢ , BUILDING PERMIT
¢ at WRMATION
u OWNER-BUILDER DECLARATION INFO
w1 u H I hereby atfirn that I am exempt from the Contractor's License MISC.- REFER TO ORD
F u o¢ Law for the following reason.(Sea 703 1,5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION
¢ my Code:Any city orcounty which reyuiresa permit to construct.alter, ELEC.CONTE. LIC NO.
Q 0 improve,demolish,or repair any stnleturc,prior to its issuance,also ELEG.
so
G u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
a w es - he is licensed pursuant to ilia provisions of the Contractors License
r r Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe �+
iness o Busiand Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE `-I r oRJ`1 Lit,
¢ F p the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
u ; m by any applicant for a permit subjects the applicant Ra civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(SS00).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole comperatticn,will do the work.and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,CON D. 5.00
Code:The Contractor's License Law does not apply to an.watt of
property who builds or improves thereon.and who does such work FIXTURES-PER TRAP 5.00 so.ET.FLOOR AREA TOTAL ACREAGE
_� himself re through his own employees,provided that such improve-
ments are not fntcnded or employee sale lL ed that such
he building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,ilia owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
prove for purpose ofsale.). INDUSTRIAL WASTE INTER3000 RES IND CON PB Other
❑ 1,as owner of the property,am exclusively contracting with . .
❑ O
licensed contractors to construct the project(Sec. 7044,Business 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 contractors)licensed pursuant to
the Contractor's License Law. SEWER-SAN ITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ l am exempt under Scc. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKI:RS'COMPI:NSA'I'ION DECIARAI ION WATER TREATING EQUIP.' 5.00
I hereby affirm that I have a certilic;de of mnstan to self-insure, ZONING s
or a certificate of Worked IENG
Compensation Insurance,.r a certified .SITE NO.
--,7L copy thereof(Scc.3800,Lab.C.).
I'ohcyNo. Company ,�c^- t�r1 1 ,
❑ Certl rci"its hereby for-'llishcJ" - FIRESPRINK ENERGYT-24
Z Z ❑ Crtli1'icd capY.b IileJ with thh cit division.
O Applicant - MISC.- g REFER TO ORD. Y EJ NE] Y ❑ N�
CISR'1'Il*ICA'TIi OP IiXITIPTI N1°EDM WORKHRS' PERMIT ISSUANCE 1040W FLDOD ZONE A.L.U.C.
LL > COMPENSATION INSURANCE PLG.CONTE. LIC.N0, 'TOTAL 71- v N v N0
Z Z (Phis section need not be completed if the permit is for one
hundreddollars($100)or less.)
U O I certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,1 shall not employ any person in:my manner so as to
_ U become subject to the Workers'Compensation Laws of California.
U C.w Datc Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} m NOTICE 1'0 APPLICANT: If,after making this Certificate of Lie-
F 2 emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forhwith Comply with FEE
U such provisions or this permit slmll be deemed revoked. AIR HANDLING UNIT(TO 10=17-F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
ilia performance of ilia work for which this permit is issued(See. MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
it formation is state,. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING 72
ordinances and correct,
a refining In building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
Osi agree to save, indemnify and keep harmless ilia City of MISC.- REFER TO ORD,
Cupertino against IiahilRies,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in con'
cyuence of the
Broiling of this permit. MECH.CONT. LIC.NO. MECH.
-�" TOTAL TOTAL
SI na - p 'can Cb o
INSPECTOR COPY