8197 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FI CATION PERMIT NUMBER
HDILDING .Z nig APPLICATION & PERMIT ^�
-�.
ADDREss l
�
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
2 NAME PLAN CHECK VALIDATION:"
ft
7 QTY. ELECTRIC PERMIT FEE
1� CONTRACTOR'S
NAME , UTLETS-SWITCHES-RECEP 10.00/1.00
+ -rLIGHTING FIXTURES 10.00/1.00
/ I LIC.ND.
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
'AD/p'�HESS r e 11 F
V SN,eM c- PHON PANELS 10.00 DATE OF APPLICATION
D
PANELS (OVER 200 AMPI 20.00 PLAN CHECK FEE P.C.NO.
ENcmEE ^ SIGNS TRANS. 3.00
ADDRESS f�.,�/ SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
(,•�,J� iIEMP. METER OR POLE INS. 20.00
APPLICANT
AODRMOTORS SEE FEE SCH.
E55 \ / �J
SERVICE /---
CHANGE 20.00
Doo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 r
See, I hereby affirm that I am licensed under provisions of Chapter 9 1 ISSUANCE DATE
I- z w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
FD i Professions Cod• rid my license is in full f
z 0 - License Class Lia Numbe _ ❑ � ❑
z r w/ Dute- Contractor
m IS �- BUILDING PERMIT
¢ ¢ w o h ili-BUILDER DECLARATION INFORMATION
wu H I hereby al Gem that I am exempt from the Contractor's License MIS[.- REFER TO ORD yq LUATION 5/FT.
F u o a Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
R Q.Q 0 improve,demolish,or repair any ihuc[ure,prior to its i5suante,aISU ELEC.CONTR. LIC.NO. ELEC.
0 0 requires the upplicavl for such permit to file a signed statentrnt that TOTAL PERMIT TO
A
m" he is licuucd pursuant In the provisions of tire nte Cometer s Limnse
La _^J
La Law(Chapter9(commencing with Section 7000)of Division3 ofthe
4 0. Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE P
IS 0 the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR..
In 5; by any applicant for a permit subjects oro applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars($500).):
❑ I,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 P ol'essions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License-Law does riot.apply to an owner of
property who builds or improves thereon,and who does such work F I XTUR ES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employers.Provided thus such improve-
memsare (]trouhh is of oremploffered for sale.provided
such
building GAS-EA.SVSTEM-111NC.40UTLETS 6.00
or improvement is sold within one.year of completion,the owner- GAS EASYSTEM-OVER 4 (EA) 200
builder will have the burden of proving that h - . . .
e did not build or int- BUILDING USE
move for purpose ofsale.). - INDUSTRIAL WASTE INTER. 30.00 RES IND CON . HE Omer
❑ I,as owner of the property,am exClusively contuan ing.with ❑ ❑ ❑
x licenxd contractors to construct the project(See, 7044,•Busin6s 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 contractorl s)licensed pursuant to -SANITARY-STORM EA.200ft 10.00
the Contractors License Law. SEWER / TRACT NO. PARCEL NO.
❑ 131n-exempt under Sec. ,B.&P.C.Ibe this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.GATE ACG FILE NO.
WORKERS'CO,MPENSATION DECLARATION WATER TREATING EQUIP, 5.00
I hereby affirm that I have a certificate UI consent to set&insure. '
or a certificate of Workers'Cum emsation Insurance,or a certified 7 ZONING ENG.SITE NO.
copy t he•of f Sec.3800,LohC. {
Policy'N. Ca m puny
0 J3(Ccr it d ms hereby is �� FIRE SPRINK ENERGY T34
Z �t'er py is riled_with the city inspection division. -
p A nt - MISC.- REFER TO ORD, y❑ NE] v ❑ N�
CC CCK IC PNCE TION9tROht WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE ALU.C.
UJ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
Q. C3( 'Phis section need not be completed if lire permit is for one TOTAL V N V ❑ IN[]
hundred dollars 181001 or less,)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
)- mit is issued,I shall not employ any person in any manner so as In
U become subject to the Workers'Compensation Laws of California.
i Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTIC17 TO APPLICANT': If,after making this Cento"te of Ex-
♦- ? an prior.you should hecume subject to the Workc,,,Compensution APPLIANCE 5.00 ,. PLAN CHECK
provisions of the Labor Code, you must forthwith comply will FEE
U Such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.)5 14.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MCF.M.) 6.00 SEISMIC FEE . l 30
1 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,Cie.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information n correct I agree to comply with all city and county PLUMBING
ordinances and state laws relating to comply
building construction, and BOILER--COMP I3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000BTUI SEE FEE SCH. MECHANICAL
above-nmnlioned 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 10.00 CONST.TAX
in any way accrue against said City in consequence of the
a i his permit MECH.CONT. LIC.NO. MECH.
X Rat an trade
3 TOTAL TOTAL s/LS
NJ
INSPECTOR COPY
. I