6180 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
• BUI7-DI NG PROJECT I DENTI FICATIO PERMIT NUMBER
'BUILDING APPLICATION & PERMIT O
AOGREss BUILDING - ELECTRICAL-PLUMBING-MECHANICAL618
osis-io�ia w
OWNER'S PLAN CHECK VALIDATION
�NAM^E //'r QTY. ELECTRIC PERMIT - FEE
rx " ` HONE
CONTRACTOR',NAME UTLETS-SWITCHES-RECEP 5.00/1.00
(� II
CLp>� LIC.No / LIGHTING FIXTURES 5.00/1.00,,o
ADDRESS
PPLIANCES-RESIDENTIAL 4.00
CONTRAS
�P7 ONE p PANELS 5.00 "6,r DATE OF APPLICATION
ARCHITECT SIGNS 6.00
PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.NO. SIGNS TRANS. 3.00
ARCHESS 08 ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP p� EMP.METER OR POLE INS. 15.00
ADINESSCANT
ADP+ESS L?' MOTORS SEE F CH.
/ J
SERVICE CHANGE .00
wo LICENSED CON"IRACTORS DECLARATION
U�. I hereby affirm that I an Beeosed under provisions of(Chnple,Y ISSUANCE DATE
vHi<N (vommcncing with Section 7000)of Division 3 of the Business and BLDG. ELECT.I PLG. MECH.
F N z Professions Code and my license Is in full fore•and of ❑
z O w - Licenx CI ss &/O Lic.Number y p�
Q z F w Dae Conta"ro ElITa y E BUILDING PERMIT
w ¢
OWNER-BUILDER DECLARATION
"INFORMATION
FOU " MISC:- REFER TO ORD ^- -
w 3 LL N 1 hereby affirm that I am exempt from the Contractor's License
VALUATION $/FT.
F u o sc Law for the following reason.(Sec.7031.5,Busincssand Professions PERMIT ISSUANCE 6.00 A
Cade,Any city or county which requires a permit to construe(,alter,
rtQ 40 inrpmve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC. .[
-O u requires the applicant for such permit to file a signed statement that TOTAL`J PERMIT TO
n w m he is licensed pursuant 41 the provisions of the Contractor's License
rzi
Law(Chapter 9(commencingwith Section 7000)of Division3ofthe ELEL
a Business and Professions Coded or that he isexempt therefrom and QTY. PLUMBING PERMIT FEE
a F o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
51 by hyany applicant For a permit suhj,os the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars($500)):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
• their sole compensation,will do the work,and the structure is not
intended ur offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:'rhe 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 4.00 SO,FT.FLOOR AREA TOTALACREAGE
• himself or through his own employees.provided that such improve-
Mentsarenotintendedorofl'ored for sale If,huwcver,the budding GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
build,,,will have tiro bmdml of proving that he did not build or fill- RES IND CON PB Olne,
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project ISec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PAHCE L NO.
and Professions Code:fire Contractor's License Law dues not apply
IN
an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
unracls for such projects with u contractor(,)licensed pursuant 1.0
the Contmco',License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ tum cxcnuprundcr sec ,0.&I'.C.for this WATER HEATER W/VENT 4.00
ft'aS011
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK Ii RS'C'OMPFNSA'IION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm thal I have a rortifcaW of consent to sett-insurer. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance.or a certified
nrpy Uen.•nf l Sec.3800,Lab.C.yy
I' ,cJyCi•U
�c'r. Company CPJ'het+'�"3���
ilieA copy is hereby famished. FIRE SPRINK ENERGY T 24
Z 2 ❑ Ceitihe o .Mile wit], th- itv inspection Division. MISC. Y- REFER TO ORD.
O ApPlicnnlC,�p ❑ N❑ Y ❑ N❑
N CERTII"ICA11:OI'EXEMPTION FROM WORKERS, PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
d O ('Phis section need1 riot
lieT`omple ed 01,1 Rf the permit is for one PLG.DONTR. uC.rv0. PLG. ❑ ❑ E] ❑
TOTAL N Y N
2 hundred dollars(5100)or less.)
U O 1 certify thus in the poformance 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 to
LL U becmne subject 10 the Workers'Compcmution laws of Calif on+i..
O w Date Appl{cant - ALTER OR ADD TO MECH. 4.00 BUILDING
} m NOTICE '1'0 APPLICANT: Ir,after raking(Itis Certificate of IN-
F. ? en.ption,you should hecome suhject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3077,Civ.C). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC SpZd
Lender's Address
I certify that 1 of read this application and sae that the above VENTILATION FAN (SINGLE) 3.00
information is correct. 1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction,and BOILER-OOMP(3 H.P.Or 100,000 B.T.U.) 4.00
hereby aulhorim repmentalives of this city to enter upon [lite BOILER-COMP(Over 100,000BTU1 SEE FEESCH. MECHANICAL
above mentioned properly 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
miry in any wily accrue against said City in consequence of the
gr�1 ''p• nil. MECH.CONT. LIC.NO. MECH.
�� r /O��&� TOTAL TOTAL
�ignnNre of pp Tran(/Contactor aI,
OFFICE COPY