8190 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
7 ADDRESS
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL8190
// OWNER'S PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
ONE
CONT ACTORS
NAME OUTLETS-SWITCHES-RECEP .10-OOL7.00 yc
LIC.No. LIGHTING FIXTURES 10.00/1.00
CONTRACtOms APPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.N0.
OR PANELS (OVER 200 AMPI 20.00 '
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
/ ARCH.OR ENG. PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00
ZIP EMP.METER OR POLE INS. 20.00
ASMOTORS SEE FEE SCH. J
•
ADDREOREsS
SERVICE CHANGE 20.00 (�
w o 0 LICENSED CON TRACTORS DECLARATION TEMP.POLE 30.00 .1//
Q 0 1 hereby affirm that am licensed under provisions of Chapter 9 ISSUANCE DATE
% (commencing with SectioT7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r mi Professions Code and my license is in full force and effect. ❑ ❑ El
0 w - License Class �i9 Lic.Number r
0 z r Date -/j-Qr Contractors
F -
vt BUILDING PERMIT
¢ ¢ w ¢ j OWNER-BUILDER DECLARATION INFORMATION
0 ° f MISC.- REFER TO ORD
X g 4 U.m 1 hereby affirm that 1 am exempt from the Contactors License " VALUATION $/FT.
¢0 ¢ Law for the;following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 1p.00.
vs Code:Any city orcounty which requires a permit to construct,alter,
2 ¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO, ELECIJ SS
¢ requires the applicant for such permR to file a signed statement that TOTAL PERMIT TO
wm u he is licensed pursuant to the provisions of the Contractor's License _
F z r Law(Chapter 9(commencing with Section 7000)of Division 3 of the
1a Business and Professions Code)or that he is exempt therefrmn and DTV. PLUMBING PERMIT FEE
, 0 the basis for the alleged exemption.Any violation of Section703L5 STORIES TYPE CONSTR.
a3`O by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars(55001.):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RIES.UNITS
their Sole compensation,will do the work.and the structure is not
intended or offered for sale'(Sco 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 work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such impwvr•--.
meets are 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 im - BUILDING USE
RES IND eOry PB ohne,
prove for purpose ofsole.). k INDUSTRIAL WASTE INTER. 30.00
❑ 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 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 contactoms)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 - TRACT NO. PARCEL No.
- ❑ 1 am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPEN'SATION 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 N0.
copy thereof(Sec.3800,Lab.C.).
Policy No. Co n.puny -
O ❑ Cerlifmd copy is hereby rurnished. FIRE SPRINK ENERGY T-24
Z Zia fjlic.ol lied c y rs fled w��J'���rrrr tl n ectiun division. MISC.- REFER TO ORD. ❑ ❑ ❑ ❑
O ' Applicant� �..�G Bel Y N Y N
w CERTIFICATE OF EXEEMPTION 17ROM WORKERS' PERMIT ISSUANCE 10.00 FLOOOZONE A.1-L.I.C.
LU > COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
CL Z (This section need not be completed it the pern.it is for one TOTAL V❑ N❑ V ❑ N❑
hundred doil or,($100)or less.)
U O 1 certify that in the performance of the work for which this per. CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued, I shall not employ any person in any nwnner so as to
O become subject to the Workers Compensation Laws of California.
d Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} 0 NOTICE TO APPLICANT: If,alter making this Certificate of fix
Z emptlon,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 10=C.F.M.I 4.00
CONSTRUCTION L17NDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a canstruch lending agency li.r EXHAUST HOOD (WITH DUCT) 5.00
3097,the eCiv.C.) . e of the work for which this permit u issued(Sec. MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lenders Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lenders Adders, ELECTRIC _-
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and counly PLUMBING
ordinances and state laws relating to building con,IDation, and BOILER-COM P(3 H.P.or100,000B.T.U.) 6.00
hereby nutoncdproperty for ins of this city to cntcr Inion the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
' above-mentioned properly for inspection purposes.
(We) agree to Save, indemnify and keep barnhluss 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'ugainst said City in consequence of the
granting thispennlL MECH.CONT. LIC.NO. MECH.
\ /Z IOTA` TOTAL
,'` Si naTure p Cod rector Dat,
INSPECTOR COPY