8580 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT IDENTIFICATION PERMITNUMBER
,BUILDING APPLICATION & PERMITADDRESS
r O
• 0 O [.g/ H
BUILDING-ELECTRICAL-PLUMBING-MECANICAL
OWNER'S ! PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
HONE
NAME Across UTLETS-SWITCHES-RECEP 10.00/1.00
uc.No_ LIGHTING FIXTURES 10.00/1.00
CONT Acrons APPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE 01ft PANELS 10.00 DATE OF APPLICATION
RCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. ISIGNS TRANS. 3.00
ADDRESS ENC' SPECIAL CIRCUIT 5.0D PERMIT VALIDATION
zhv TEMP.METER OR POLE INS. 20.00
AESMOTORS SEE FEE SCH.
S
ADDRDDRESS
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATIONTEMP.POLE 30.00 �7lv
a v I hereby affirm that I um licensed under Provisions of Chapter 9 ISSUANCE DATE
yaw (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLC. MECH.
F w,o Professions Code,and my license is in full fur5,�a-nd effcef16s.
Zo i v2 W License Class Lie.Number�l�}- ❑ ❑ ❑
Date_� �_v5 Contractor-C�.
a x f J BUILDING PERMIT
¢ ¢ w < OWNER-BUILDER DECLARATION INFORMATION
o A U MISC.- REFER TO ORD
E:
; u vi 1 hereby affirm that I am exempt from the Contractors License VALUATION $/FT.
F LL 0 4 Law for the following reason.(Sec.703 1.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct alter.
Qa ¢ o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NQ ELEC.
0 LL
e requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w m he is licensed pursuant to the provisions of the Contractor's License ss pp
F z r
Law(Chapter 9(counmencing with Section 7000)of Division 3 of lite
f i Qo Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ I- o the basis for the alleged exemption.Any violation of-Section 7031.5 STORIES TYPE CONSTR.
n;m by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
.footmore than five hundred dollars($500).):
❑ 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 0�
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.FLODR AREA TOTAL ACREAGE
himself or through his own enhployees,provided that such improve-
mems are of intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 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 he did not build or im- RES IND CON PB Omer,
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business ILAWN SPRINKLERS a V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law dues not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OV ER 5(EA.) 1.00
contracts for such projects with a contractoRs)licensed pursuant to
Rhe Contractor's License Law. SEWER-SANIT T ME ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
rcusnm
Owner Date WATER SYSTE pe mo 5.00
ACC.GATE ACC.FILE NO.
WORK F.RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate Of consent toself-insure' ZONING
or a certificate of Workers'Compensation Insurance/err a certified ENG.SITE NO,
copy thereof(Sec.3800,Lab.C.).M/Jd,�a.N
Policy No. ColnP.mY .
O ❑ Cert it led copy's hereby furnished. FIRE SPRINK ENERGY T 24
Z 2 r�f�Certfied y is rMd ritlh the c4 inspection division. MISC.- REFER TO ORD.
O Applicant Y❑ N❑ Y ❑ N❑
ir y P.RTIFICA'rE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE ISM FLOOD ZONE A.L.0 C.
11J > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. [ -t �.
d t] (This section need not be completed if the permit is for one C/ ( ZK 3Z a TOTAL 4>� Y❑ N❑ Y ❑ N❑
2 hundred doll..($100)or loss.)
U O 1 certify that in the perfurnwnce of the work far which this Per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
1L F mil is issued,I shall not mnploy any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
0. Dale Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} w NOTICE TO APPLICANT: If,after making this Certificate of Ex-
♦- ? empfion,you should become subject to the Workers Conhpensation APPLIANCE 5.00 PLAN CHECK
provisions of tire Labor Code, you must tiullhwith 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 AIR HANDLING UNIT(OVER 10=CRM.) 6.00 SEISMIC FEE
I hereby ufl'inn that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the Pcd'ormance of the work for which this PCTMH is issued(See. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Ctv.CJ.
Lender's Name
Lender's NameAddress HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
I certify that l have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00 /�
ordinances is rotate[.I agree togillcomply with all city and county PLUMBING (P
ordinances .is state laws relating m with construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the B01 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 10.00 CONST.TAX
may in any w accrue against Said City in consequence of the
ant oft ' .p hL MECH.CONT. LIC.NO. MECH.
�� TOTAL TOTAL
ignatur pplicamt/Contractor Date
OFFICE COPY