7243 APPLICANT TO FILLIN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER BUILDING APPLICATION & PERMIT
ADDRESS5
DDRES5
YUILDING — ELECTRICAL—PLUMBING—MECHANICAL 7243
OWNERS PLAN CHECK VALIDATION
NAME
ELECTRIC PERMIT FEE
ONE
CONTRA TLETS-SWITCHES-RECEP 5.00/1.00
NAME
r b��. D LIGHTING FIXTURES 5.00/1.00
DN R PPLIANCES-RESIDENTIAL 4.00
AADD
—
95S fj LPANELS 5.00 DATE OF APPLICATION
AR liL T SIGNS 6,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.rvo. / SIGNS TRANS. 3.00
ADDRESS ENG. PERMIT CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
AYrs
ADDDRESS - MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
woo LICENSED CON'T'RACTORS DECLARATION
¢ Lmi o I hereby affirm Thal 1 um licensed under provisions of Chapter 9 IS DATE 11
2 a- (commencing with Section 7000)of Division 3 of Ih Business Ind BLDG. ELECT. PL MECH.
z o.a Professions Code,and my license is in full far L c L
License Class Number. EJ
F 11xtc nlractor
a s -I _-� �- r BUILDING PERMIT
¢ IS w a O `TER- DILLER DECLARATION INFORMATION
0IvO MISC.— REFER TO ORD
w g LL N I hereby affirm that I am exempt from the Contractor's License VALUATION S/FT.
F LL m j law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 6.00
t, improve,Code:Any city or County which requires a permit toconstruct,alter, ELEC.CONTR. LIG NO.
¢ a o improve,demolish,or repair any structure,prior to its issuance,also ELEC.
—O¢ myuires the applicant for amt,permit[o file a signcA statement that TOTAL pEq MIT TO
K
m" he is licensed pursuant to the provisions of the Contractor's License Y/�
r z i Law(Chapter 9(annmencing with Section 7000)of Division 3 of the
a Business and Professions Code)or that he is exanitl therefrom and OTY. PLUMBING PERMIT FEE
2Hp th c basis for the alleged exemption.Any violaliotolSection7031.5 STORIES TYPE CONSTR.
d — _ by any applicant for a permit subjects the applicantto a civil penally ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars($5001):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 oCC.GROUP RES.urvris
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. 4.00
Code:The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTALACREAGE
\� himself or through his own employees,provided that such'in
prove-
m
r nras are not intended proffered for sale.If,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 4.00
improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 100 BUILDING USE
builder will have the burden of pn ving that he did not build or im- .- RES IND CON PB Ohher
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20-00
❑ 1,as owner of the properly,am exclusively contracting wilt, I ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5-00 ASSESSORS PARCEL NO.
and Professions Code:'I'lie C'ontractor's License Law does not apply
to an owner of properly 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 Conlmctph License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,N.&P.C.for this WATER HEATER W W /VENT 4.00 1
reasonn
Owner Date ATER SYSTEM 4.00 ACC.DATE ACO.FILE NO.
WORK ERSCOMPENSATION DECLARAT'1ON WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent Rr self-insure. ZONING ENG.SITE NO.
or a certificate<f W tion Hif
Po'
O op sh rtb ( shcJ. FIRESPRINK ENERGY T 24
Z Z ❑ Cer"ed top file i t e •ati n i i o . MISC.- REFER TO ORD.
F O Applicant Y❑ N❑ Y ❑ IN
ir W CE IIICA71 OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 rii/FLOOD ZONE A.L.U.C.
W > COMPIiNSATION INSURANCE PLG.CONTR. LIC.NO. PLG. 1 Z V El N❑ Y❑ NE]
section need not be completed if tile permit is lir, one TOTAL
hundred dollar's IS 1001 or less.) r
U O 1 certify that in the performance of the work for which this per- OTV MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any perwn in any manner so as to
U become subject to the Workers'Compensation Laws of California. BUILDING
n Date Appheant ALTER OR ADD TO MECH. 4.00
.} t7 NO'TICF.TO APPLICANT: If.after making this Certificate of Ex-
f" ? eruption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U
net,provisions Lir this permit shall be deemed revoked. AIR HANDLING UNIT(TO 109=MC.F.M.) 3.00
CONSTRUCT[ON LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction finding agency for EXHAUST HOOD(WITH DUCT) 2.00
the performnnec of the work foowhich this permit is issued(Sec. MICROFILM
3097,Cis C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B. .U. 7.50
Lender's Name HINNR T )
ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
l• information is correct. I agree to comply with all city and county PLUMBING
ordinances and stale laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorise representatives of this city to enter upon the BOI LER-COMP (Over 100,000 BTU)SEE FEE SCH. 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 PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against said City in Co sequence of the
fV grueling of this Penni. CONT. LIC.N0, MECH. O
TOTAL TOTAL O
ign urs ofA phi ontractor ate
INSPECTOR COPY
i