9331 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LD1 NG PROJECT I DENT[FICATION PERMIT NUMBER -
BUILOING APPLICATION & PERMIT
AOOREss 933
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
O �TQI 8
OWNER'S PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
O.E cTORs
NOUTLETS-SWITCHES-RECEP 10.00/1.00
AME
Lc.NO. LIGHTING FIXTURES 10.00/1.00
ANTRA SSTOR's
ADDREAPPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
RcwrEOT_ PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.No.
OR O
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS..,_. ` ... ..
ZIP rrEMP.METER OR POLE INS. 20.00 ^ /�
APPLICANTS
ADDRESSMOTORS SEE FEE SCH. /
SERVICE CHANGE 20.00
,00 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
¢ u u I hereby affirm That I in licensed under provisions of Chapter 9 ISSUANCE DATE
m z w (commencing with Section 7000)of Divisims 3 of the Business and BLDG. ELECT. PLC. MECH.
H m z Professions Code,and my license is in full force and effect El ❑ El 1:1z a w - License Class Lie.Number
o w-o Date Contractor
¢ m f BUILDING PERMIT
¢ ¢ w a OWNER-11101 LDBR DECLARATION
INFORMATION
aoA MISC.- REFER TO ORD
w S u_ I hereby affirm that 1 am exempt trete the Contractor's License VALUATION
F lcoa Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,aheq
¢ ¢ o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
S m u requires the applicant for such pun oil to file u signed statement that TOTAL PERMITTO
n w he is licensed pursuant to the provisions of the Contractor's License
F z aLaw(Chapter 9(commencingwith Section 7000)of Division 3 ofthe /
Business and Professions Code)or that he is exempt therefronl:md OTY. PLUMBING PERMIT FEE EN GE
¢ r$ the basis for the alleged exemption.Any violation of Section 7031.5 oi) STORIES TYPE CONSTR.
a3 _ by any applicant for a permit subjects lite applicant to a civil penalty ALTER-DRAIN -WATER IEA.15.00
of not more than five hundred dollars(55001.1:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE L00 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:'(he Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work F IXTURES-PER TRAP 5.00 SO.FT,FLOOR AREA TOTALACREAGE
hunsell re through his own employees,provided that such ibuildi c
msnelfo notintendedoroemplofor su c.provided
that suheicloi e. GAS-EA.SYSTEM-11NC.4OUTLETS 8.00 1
or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 'BUILDING USE
provefkt purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Dm4r
I:]/I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
IicLLLL•n,cd convectors to construct the project(Sec.7044,Rosiness 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 propqeerty who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such 4ojects With a comma. I)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors cen5)Ww. TRACT NO. PARCEL NO.
❑ tum ex• t Cry• .B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner I Date RI{gfg WATER SYSTEM 5.00 ACC.DATE ACC.FILE N0,
WORKERS'COMPFNSA'I'ION DGCLARAT ION WATER TREATING EQUIP. 5.00
1 herchy affirm floor I have a certificate of consent loself-insure,
or n certifcme of Workers'Compen,ation Insurance,or a certilled ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.)-
policy No, Conrpuny
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
z Z ❑ Certified copy is RIeJ with rte city inspection Division. MISC.- REFER TO ORD.
O Applicantv ❑ N❑ V ❑ N
y CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOOZONE A.L.U.C.
LU > COMPENS ZION INSURANCE. PLG.GONER. LIC.NO. PLG.
U (This section need not be completed if the permit is for one TOTAL YE] N❑ Y❑ N❑
Z hundred dollars(SI00)or less.)
U 0 1 certify that in the perlonnunee of the work for which this per QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H Init is issued,I ,hall not employ any person in any manner so as to
U becoln c subject to the Worker,'Compensation Laws of California.
DO
Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} s21
W NOI'ICF, '1'O APPLICANI: I(,after making this Certificate of lis"
Z anp(ion,you should become subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK
Provisions of the Labor Code, you must forthwith comply with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M) 4.00 ' FEE
CONSTRUCT ION LCNDING AGENCY AIR HANDLING UNIT(OVER 10p00C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
re performance ante of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00
a
Lender's Name
Lender's NamAddn, HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
c,
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• In Rnnution is correct I agree to comply with all city and county PLUMBING
ordinances and sure laws relating to building construction, and BOILER-COMP 13 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city m enter .,on the ,
above-mentioned property for inspection purposes. BOILER-COMPIOYer 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree/to save, indemnify and keep harmless the Cityof MISC.- REFER TO ORD.
Cupertino a 5inM liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in�n w acct against said City in consequence of the
gianlingo th' rmi MECH.CONT. LIC.NO. MECH.
/ t TOTAL TOTAL
y� Sig1l fu Contractor � at /
/ \ INSPECTOR COPY