C8495APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT 1 DENTI FICATI ON
APPLICATION &PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
f�' ��
BUILDING
018 '
NAME
QTY. ELECTRIC PERMIT FEE
'. PLAN CHECK VALIDATION
PHONE
c NT oRs
ry
OUTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
LIC.NO.
c ry R c
ADDRESS
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.06
PHONES
DATE OF APPLICATION
OR RCIE
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. No.
ENGINEER
LIC. No.
SIGNS TRANS. 3.00
ADDRESS ENG,
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 20.00
-
lip
��� ('
APPLICANT'S
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
J
i f
LICENSEDCON'1' RACTORS DECLARATION
TEMP. POLE 30.00
1 hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full for a an I effect
License Class C_Lie Number
'5-. Contractor
Uatefa�3.�
OWNER -BUILDER DECLARATION
1 herebyMISC.
by affirm that I um exempt from the Contractor's License
Law for the following reason, (Sec. 7031.5. Rusinessand Professions
Code: Any city or County which requires a permit to construct alter.
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to Rica signed statement that
he'is licensed pursuant to the provisions of the Nninetor's License
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
ISSUANCE DATE
BLDG.
❑
ELECT.
❑
PLG. MECH.
❑ ❑
BUILDING PERMIT
INFORMATION
- REFER TO ORD
PERMIT ISSUANCE 10.00
I
VALUATION
`
lJ
5/FT.
ELEC. CONTR. LIC. NOy.1
ELEC.
TOTAL
PERMIT TO `
/
QTY. PLUMBING PERMIT FEEthe
STORIES
TYPE CONSTR.
basis for the alleged exemption. Anv violation of Section 7031.5
1
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars (SSOO).):
ALTER -DRAIN -WATER IEA.) 5.00
❑ 1, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
BACK F LOW PROTECT. DEVICE 4.00
DCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA,COND. 5.00
intended or offered for sale (Sc,. 7044, Business and Professions
Code: The Contractor's License Law docs not apply to an owner of
property who builds or improves thereon, and who docs such work
himself or through his own employees, provided that such improvr
menu are not intended or offered for sale. If. however. the building
FIXTURES - PER TRAP 5.00
'SD. FT. FLOOR AREA
TOTAL ACREAGE
GAS - EA. SYSTEM -11NC. 4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner-
builder will have the burden or proving that he did not build or im-
prove for purpose of sale.). It
❑ I, as owner of the properly, am exclusively Contracting with
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON PB Omer
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct thepRR t,(Sec. 7044, Business
and Professions Code The Contractor's License Law does not apply
to an owner of property who builds or improNs thereon. and who
contracts for such projects with a corumctORs) licensed pursuant to
the Contractor's License Law. y
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO. .
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO,
PARCEL NO.
❑ 1 am exemof under Sec. ,B.&P.C. for this
WATER HEATER W/VENT 6.00
reason
Owner ' Date
WATER SYSTEM 5.00
Ace. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
WORKS RS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure,
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof(See. 3800, Lab.C.I P
Policy No. Company
❑ Certified copy is hereby furnished
/y Cenil icd copy is filed with the city inspcctton division.
A Pmunt
e
FIRE SPRINK
Y❑ N❑
ENERGY T-24
Y❑ N❑
MISC. - REFER TO ORD.
CER'FIFICA -OP EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.U.C.
PLG. CONTR. LIC. NO.
PLG.
TOTAL
CON INSURANCE
(This section need not be completed if the permit is for one
Y ❑ N ❑
Y ❑ N ❑
hundred dollars (S 100) or Tess.)
I certify that in the performance of Lhe work for which this per-
mit is issued, I Shall not employ any person in any manner so as to
OTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
JU
become subject to the Workers' Compensation Laws of California.
Date ApplicantALTER
OR ADD TO MECH. 5.00
NOTICE '10 APPLICANT: IC after making this Certificate of Ex-
APPLIANCE 5.00
AIR HANDLING UNIT (TO 10,00DC.F.M.) 4.00
PLAN CHECK
FEE
�O
emption, you should becomesubject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT(OVER IODWC.F.M.) 6.00
SEISMIC FEE'
Sv
CONSTRUCT ION LENDING AGENCY
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 (See
3097, Civ.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address
HEATI NG UNIT (OVER 100,000 B.T.U.19.50
ELECTRIC
I certify that I have read this application and statC that the above
VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
PLUMBING
BOILER-COMP13 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP IOvar 100.000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
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
may in any way accrue against said City in consequence of the
CONST. TAX
'PERMIT ISSUANCE 10.00
granting of this permit.
�. n ��
MECH. CONT, LIC NO.
MECH.
TOTAL
TOTAL
S TI to t o Contractor
INSPECTOR COPY