11570 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUIL ING PROJ%CT_LPENTI FICATI ON PERMIT NUMBER
91tw
APPLICATION & PERMIT 0
fn 10 Del BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
PLAN CHECK VALIDATION
.�� AC NLT� Q ELECTRIC PERMIT FEE UTLETS-SWITCHES-RECEP 10.00/1.00
1 ^^ uc.No. '� LIGHTING FIXTURES 10.00/1.00 I On JYh PPLIANCES-RESIDENTIAL 4.00
J PRONE � _J PANELS 10.00 DATE OF APPLICATION
OR
PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENG.
SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 ,, ,t....�
ADDRESS Nab LP�hQ�h MOTORS E FEE SCH.
ADDRESS r -r
SERVICE CHANGE _ 20.00
O o o LICENSED CONTRACTORS DECLARATION
a u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w Q uai (emmmencanx with Section 7000)of Division 3 of the Business and O BLDG. ELECT. PLG. MECH.
F h i Professions Code, license is in full Tod i �� ❑ ❑ ❑
O License, Lic.Number. 1 yy��
o N F, Date _Contract., CSL)
< iz 2 ¢ OWNGR-BUILDGR DECLARATION BUILDING PERMIT
_ SE w O INFORMATION
X
;LL I- I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION $/FT.
F IL TOA J 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,
re ¢ s- 0 improve,demolish,or repair any structure,prior to its issuance,also E DNTR, LI .NO. %LEC.
O IS requires the applicant for such permit to file a signed statement that TOTAL / PERMIT TO
w w he is licensed pursuant to the provisions of the Contractor's License
Hi> Law(Chapter 9(commencingwith Section 7000ofDivision3 ofthe
14 o Business and Professions Code)or that he isexempt therefrom and QTY. PLUMBING
fessioPERMIT FEE
Ie H $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500).)'.
❑ 1,as owner of the property,or my employees with wages as BACKFLOW 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
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 .50.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve GAS-EA.SVSTEM-11NC.40UTLETS 6.00
ments are not intended or offered for sale.If,however,the building
or Improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Orae.
.
prove for purpose of sale.). INDUSTRIAL WASTE INTER30.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business 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 properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA,) 1.00
contracts for projects
such pects with a contractor(s)licensed pursuant to
the Contractor's h roLaw. SEWER-SAN ITAR V-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5,00
I hereby affirm that I have a certificate ofconscm to self-insure,
or a certificate of Workers'Compe sat.on I stinne ora cerlified ZONING ENG.SITE N0.
copyther e 8 Lab.C.).
PolicyN any_
Q ❑ Certi le coryo-
py is ¢ by R ' sed. FIRE SPRINK ENERGY T 24
Z ❑ CertifRdlgp) fi •d itlt t c s,c bn - V division.
APPlicaMISC. REFER TO ORD. ❑ N V N❑ ❑ ❑
� - nt_�
it - CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C.
LU COMP17NSATION INSURANCE PLG.CONTE, LIC.NO. PLG. v❑ N❑ V ❑ N❑
CL O (This section need not be completed if the permit is for one TOTAL
D Z hundred dollars($100)or less.)
U O 1 certify that in the performance of the work for which this per. OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
0 Ed Date Applicant ALTER OR ADD TO MECH. 5.00 rE
} w NOTICE TO APPLICANT: If,after making this Certificate of Ex-
? emption,you should become subject to the Workers'Contpensatimn APPLIANCE 5.00
provisions of the Labor Code, you must forthwith comply with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVEA 10=C.EM.) 6.00 I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the 3097 eCiv.C.jnce of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9,50
Lender's Address
I certify that I have read Ihisapplication and ,are that the above VENTILATION FAN ISINGLEI 4.00
information is correct. I agree to comply with all city and county, PLUMBING
ordinances and state laws relating to building 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 BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
I 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 CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
gran ng f this permit. MECH.CONT. LIC.NO. MECH.
VILk U'�X 11alI K TOTAL TOTAL
`./ SI ature of Applicant/Contractor ate
J OFFICE COPY