10271 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENT[FICATIOJQTY.
PERMIT NUMBER
APPLICATION & PERMIT O^ I� ^
nlrvG (� I I
no eR s
DING - ELECTRICAL-PLUMBING-MECHANICAL
rvER's ' PLAN CHECK VALIDATION
NAP ELECTRIC PERMIT FEE
Rrvnme ncaGRsOUTLETS-SWITCHES-RECEP 10.00/1.00
uc.No. LIGHTING FIXTURES 10.00/1.00
f-ONTRACTOR'S
pREss APPLIANCES-RESIDENTIAL 4.00
PHON ( PANELS 10.00 DATE OF APPLICATION
ARCHITECT
OR PANELS (OVER 200 AMP)' 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
uc.NG. SIGNS TRANS. 3.00
ADDRESS ENa _ SPECIAL CIRCUIT 5.00 PE RMITVALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT'S - SEE FEE SCH.
APPLICA T' MOTORS "-
"�.T SERVICE CHANGE 20.00
.-w'0 0 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
¢i w 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
Q A (commencing wit Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H w i Professions Ca �d cense is in full for C feet. ❑ ❑
o i m O License lass Lic.Number
R w r Dete C ntractor �..hAp .
a y J BUILDING PERMIT
¢ ¢ w
OWNER-BUILDER DECLARATION INFORMATION
w3 LL y 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
a_ VALUATION Law forthefomG.gmason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE - vALUanON $/F7.
at _JCode:Any city or county which requires a permit to construct,after, 10.00
R ¢ Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO.
ELEC.
0, requires the applicant for such permit to file n signed statement that TOTAL PERMIT TO
e. w he is licensed pursuant to the provisions of the Contractor's License
rzQ Law(Chapter 9(commencingwlth Section 7000)ofDlvision 3ofthe `/7Lp /s
4 4 D Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE /� O(T�
the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN of not more than five hundred dollars($500t) (EA.) 5.00
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
their sole compensation,will do the work,
and the structure is notOCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, and
and Professions -DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Cont...or's License Low 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.FLOOR AREA TOTALACREAGE
• himself or through his own employees,provided that such improve-
ments are not intended or offered forsale.hL however,the building GAS-EA.SYSTEM-1 1NC.4-OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or im BUILDING USE
prove for purpose ofsaleJ. INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ 1,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sea 7044,BusinessBIP
KLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
1:3 El El El Cl
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and whoKLERS-OVER 5(EA.) 1.00
contracts for such projects with a co ltmetor(s)licensed pursuant to
the Contractor's License Law. TARY-STORLIy1 Oft/10.00 TRACT NO. PARCEL NO.
O I am exempt under Sec. ,B.&P.C.for thisreason ER W/VE _6.00
Owner Uate EM rfj �`- C 500ACC.DATE ACG FILE N0.
WORKERS'COMPENSATION D17CLARATION TING UIP. 5.00
1 hereby affirm that I have a certificate ofconsent to self-insure,
or a certificate of W rke mpensation Insurapce,o a certifiedu e20NING ENG.SITE NO.
ropy therep((�ey_ y,B, �bQ.oC -
Policy NIX./�JCZ'ED RED
O ❑ Certified copy is hereby furnished.
Z Z e tified copy is filed with the city ins n division �' FIRE SPRINK ENERGY T-24
O pllcan MISC.- REF 0ORD. Y ❑ N Y ❑ NC]
LY W C IFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOO ZONE A.L.U.C.
LU > COMPENSATION INSURANCE P G.DO TR. IC.N PLG.
11 O (This section need not be completed if the permit is for one 1 TOTAL 6 Y N V [] NE]
Z hundred dollars IS 100)or less.)
U O 1'certify that in the performance of the work for which this per- OTV MECHANICAL PERMIT FEE FEE SUMMARY
LL U mil is issued,I shall not employ any person in any manner so as[o
0 W become subject to the Workers'Compensation Laws of California.
Is. Date Applicant ALTER OR ADD TO MECH. 5.00 'BUILDING
} W NOTICE TO APPLICANT' If,after making this Certificate of Ex-
2 volition,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT 10=C.RM.) 6.00 SEISMIC FEE
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,Civ.C.). HEATING UNIT 100,000B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OV ER100,000B.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 Taws relating to is 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
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
granting of this permt./JMECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
ature of Applicant/Contractor Date
OFFICE COPY