9474 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LD ING PROJECT I DENTIF I CATI N PERMIT NUMBER
BUILDING APPLICATION & PERMIT A n
noon L�,
BUILDING-ELECTR ICA L-PLUMBING-MECHANICAL
OWN PLAN CHECK VALIDATION
NAME // OTY. ELECTRIC PERMIT FEE
C2,,:PHONf -/
NAMERAcroR$ UTLETS-SWITCHES
-RECEP 10.00/1.00
' 0ZI:y LIc.No. 7� LIGHTING FIXTURES 10.00/1.00
CONTR
AcraRS
DDRESs APPLIANCES-RESIDENTIAL 4.00
DOHEs
yf/ iy,�fjyJ NE71I -�?-&Z/ 7 PANELS 10.00 DATE OF APPLICATION
ARCHITECTPANELS (OVER 200 AMP) 20.00 'Z PLAN CHECK FEE P.C.NO.
OR
ENGINEER Lm.NO. SIGNS TRANS. 3.00
moo ESS clue SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP. METER OR POLE INS. 20.00
APPLICANT I MOTORS SEE FEE SCH. PAID
ADDRESS
SERVICE CHANGE 20.00
AUG
w o O - LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 '20 1985
U U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
wa N (commencing with Section 7000)of Division 3 of the Business and B fffB�����•�T'. LG. MECH.
H y z Professions Co a -m license is in full force a'nd ff ty dtI o ❑
2 o w - License Cla Lie.Nwnbe-1,Q!I u
w t w Date Contractor 'fc
a s BUILDING PERMIT
X BEw u OWNER-BUILDER DECLARATION INFORMATION
E
3 LL I- 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD I VALUATION
g ( Businessand Prol'clons $/FT.
aB u D a Law for the following reason. Sec.7031.5, PERMIT ISSUANCE 10.00
Code:Any city or county which requires a pennit to construct,alter,
BE BE ap improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
0 BE I requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
o
u w es w he is licensed pursuant to the provisions of the Contractor's License
z ¢
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
4 D Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
1- the basis for the alleged exemption.Any violation of Section 7031.5 STO 5 E CONSTR.
n ; by any applicant for a pennit subjects the applicant to a civil penalty
of not more than five hundred dollars(S500).) ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 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:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SD,FT.FLOOR AREA TOTALACREAGE
• himself or through his own employees,provided that such'in
ov
pre-
. ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that Ile did not build or int- RES IND 0 PB ower
prove for purpose Of Sale.). INDUSTRIAL WASTE INTER30.00
❑ I,as Owner of the property,am exclusively contracting with . ElEl ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 A55ESS7
VPHCLL NO.
and Professions Code:'rhe Contractor's License Law docs not apply
to an owner of property who builds or improves thereon.and who LAWN SPR IN KLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contmctods)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.for Ibis WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE No.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby elfin, that 1 have n ceNificale of consent t0 sell'insure, ZONING ENG.SITE NO.
Cr a certif ca of orkeL Compensation Insurance,o� r a c
copy then f � ,Lab.C.).
Policy No mpany
❑ Cet101ed cop 's terebl'1 is ed. FIRE SPRINK ENERGY PIG
z Z ❑ Certilie y filed h city t pection division MISC- REFER TO ORD.O Applicant Y ❑ N❑ Y ❑ N❑
c CERTIF 71'01` AEMPTION 17ROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.c.
LU 1 COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL 13 11his section need not he completed if the pennit is for one TOTAL Y,❑ N❑ Y❑ N❑
=) 2 hundred dollars IS 100)or less.)
U 0 I certify that In the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F ,tit is issued,I shall not employ any person in any manner so as to
O Q become subject to the Workers'Compensation Laws of California.
a Date ApplicantALTER OR ADD TO MECH. 5.00 BUILDING r h D
} N NOTICE TO APPLICANC If.after making this Certificate of Ex-
F 2 emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK n
Provisions of the Labor Code, you must forthwith comply with FEE 04
U Inch provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONST RUCTION LfiNDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.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.) S.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.) ELECTRIC
Lender's Address
Icertify that l 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 county PLUMBING
ordinances and state laws relating to huddling ronstruclion. :md BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
Hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. g01LER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(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 against sid City 't consaqueaa of the PERMIT ISSUANCE 10.00
gmntingo [ is rmit. XMECH.CONT_ LIQ NO. MECH. s
'(� TOTAL TOTAL pZ
$tgon re of Appli nt/Cnntmctor to J
it
INSPECTOR COPY