9318 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS A
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL J
O R' PLAN CHECK VALIDATION
n N"ME QTY. ELECTRIC PERMIT FEE
PHONE
TRACTORS
o s
NAMEME OUTLETS-SWITCHES-RECEP 10.00/1.00
X ' ;7& Lt.,No. LIGHTING FIXTURES 10.00/1.00
-o r acro 's
ADDRESS PPLIANCES-RESIDENTIAL 4.00
;W PHONE PANELS 10.00 DATE OF APPLICATION
Rcmrec PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.c.No.
on
ENGINEER
uc,No. SIGNS TRANS. 3.00
moo Ess ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
ADDDRESSDRESS is
AMOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
a�N' LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
< uA I hereby,affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
CS i\' Professions Code,and my license is in full force and effect ❑ ❑ ❑
o V.-o License Class Lic.Number
Date Contractor
BUILDING PERMIT
or ¢ w u OWNER-BUILDER DECLARATION INFORMATION
o a MISC.- REFER TO ORD
w 3 LL I- 1 hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
F .. Oa Law for the following reason(Sec.703 L5,tlusinessanA Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct altet, /
or re Q o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
D or requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
wm he is licensed pursuant to the provisions of the Contractor's License
z
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
a y
Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
GE 1 m the basis for the alleged exemption.Any violation of Section 703 L5 IES TY E
a by any applicant for a permit subjects tire applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(S500).1:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.urvrTS
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: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(bat such improve.
cents are not intended or offered for sale,If,however,the building GAS-EA.SVSTEM-l1NC.40UTLETS 6.00
or Improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING
builder will have the burden of proving that he did not build or an.
BULDG USE
Prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RE IND CON PB Omer
❑ I,as owner,of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct tic 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 ILAWN SPRINKLERS-OVER 5 (EA.) 1.00
contmetsforsuch projectswith a contractor(s)licensed pursuant to SEWER-SANITAR V-STORM EA.200ft/10.00
theContractoiSLicnnsOLaw. TRACT NO. PARCEL NO.
❑ lamexemptunder See. ,B.&P.Cforthls WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE Ace.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate area...end to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab C.).
Policy Nog/ii pany ?� .y,'/�+�
❑ Ccrlle copy) rarebit fume FIRE SPRINK ENERGY T2<
Z Z 9 Certified opy is filed ith tl city inspection Division. MISC.- REFER TO ORO. ❑ ❑ ❑ ❑
O A I'll 1 V N Y N
= N - TII'UA*r,OF 1 YEM1'1'ION FROM WORM R PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C.
LL COMPENSATION INSURANCE: PLG.CONTR. LIC.NO. PLG.
CL Z (This,section need not be completed if the permit is for one TOTAL Y❑ N❑ V E] N[]
hundred dollars(5100)or Iess.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
Uw become subject to the Workeri Compensation Laws of Calhornia. BUILDING
-+) a Date Applicant ALTER OR ADD TO MECH. 5.00
} at NOTICE TO APPLICANT': If,after making this Certificate of Ex-
r Z_ mnption,you should become subject to lire Workers'Conmensation APPLIANCE 5.00 PLAN CHECK
,3 prsisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked, AIR HANDLING UNIT(TO 10MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agrm,y lix _ EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(See. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Leader:,,Name HEATING UNIT(OVER 100,000 B.T.U.)Leader's Address ELECTRIC
I certify that I have real cis application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMPI3 H.P.or 100,000 B.T.U.) 8.00
hereby authorise representatives of this city to enter upon the BOILER-COMP (Over 100,000BTU)SEE FEESCH, MECHANICAL
above-mentioned 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 CONST.TAX
may in any way accrue ug''nst said City in consequence of the PERMIT ISSUANCE 10.00
granti of this peenIll MECH.CONT. LIC.NO. MECH.
TOTAL
aturc of icant on r c Tr D_ TOTAL ata
INSPECTOR COPY