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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT lDENTIFICATION
- APPLICATION BI PERMIT
PER IT B
� II ^
4 `4J
PLAN CHECK VALIDATION
'
ADDRESS
ADDRESS
ABUILDING—ELECTRICAL—PLUMBING—MECHANICAL
s
OWNER'S
NAME -
T 7 PHONE
_ -- - - -
CITY. ELECTRIC PERMIT FEE
CONT CTOR'S
Na�mE•
OUTLETS - SWITCHES -flECEP 6.00/1.00
f- LIC NO,
-
-
LIGHTING FIXTURES 5.00/1.00 -
CONTRACTORs
ADDRESS 3�>O �(e -
PPLIANCES- RESIDENTIAL 4.00
> V Cf ^PHONE
DATE OF APPLICATION
PANELS - 5.00
ARRCHITECT -
ENGINEER
LIC. No.
SIGNS 6.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ADDREss ENG'
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 15.00
ZIP
APPLICANTS
ADDRESS
MOTORS SEE FEE SCH.
SERVICE1PERTINfl 10.00
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LICENSED CONTRACTORS DECLARATION
I hereby uffirrn that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, d m li ease is in full fe' norce fe .
e
License Class = Lie. Number
ISSUANCE OATS
BLDG.
❑
ELECT.
❑
PLG. MECH.
- ❑
Date Contractor .
PAID
s^e' -
BUILDING PERMIT
OWNER -BUILDER DECLARATION
Thereby affirm that I am exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5, Business and 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 filen signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9(commencing with Section 7000)of Division 3 ofthe
Business and Professions Code) or that he is exempt therefrom and
INFORMATION
MISC.— REFER TO ORD
_
PERMIT ISSUANCE 6.00
-
VALUATION
SIFT.
ELEC. CONTR. LIC. NO.
ELEC.
TOTAL
PERMIT TO
/k L"a/,UC• M1�Y
CITY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant ton civil penalty.
of not more than five hundred dollars ($500).1:
-
ALTER -DRAIN & VENT -WATER (EA.)4.00
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE
OCC. cflouP
RES. UNITS
DRAINS -FLOOR, ROOF,AREA,COND. 4.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
,
FIXTURES - PER TRAP 4.00
SO, FT. FLOOR AREA
TOTALACREAGE
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
ments1 are not intended or offered for sale. If, however. the building
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that Ire did not huild or im-
prove for purpose of sale.). -
as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM -OVER 4 (EA.) 1,00
BUILDING USE
RES IND CON PB ,Omer
El El El El 1:10
INDUSTRIAL WASTE INTER. 20.00
licensed contractors : construct e the project (Sec. 7044, Business
Contractor's License Law dues not tapply
to Professions Code: The who who
to an owner of property who builds improves thereon, and who
LAWN SPRINKLERS - 1 INC 5 V.B. 5.00
LAWN SPRINKLERS -OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
contracts for such projects with a contraclortsl licensed pursuant to
tr
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 2001t/8.00
TRACT NO.
PARCEL NO.
rear ❑ I am exempt under Sec. B.S.P.C. for this
son
WATER HEATER W/VENT 4.00
Date Owner
WATER SYSTEM 4.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 4.00
- WORKI:RS'COMPI:NSAI'ION DECLARATION
1 hereby affirm that I have a certificate of consent to self -insure,
or a certificate of Workers' Compensation Insu�r/�nce, oly cc lified
copy thereof (Sec. 3800, Lah.C.). AC i O
ZONING
ENG. SITE NO.
-J 1�
Policy No. Company e4 � /
FIRE SPRINK
y N
ENERGY T-24
Y NE]
❑ Certified copy is hereby furnished.
ApplicaerI" c y(/f��1Iedomed with the city i eefon division.
MISC.- REFER TO ORD.
CfiRTIFICAI'E O- FIiXEMPTION FROM WORKERS'
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.L.U.C.
PLG. CONGA. LIC, NO.
�IYrP a�I'
TOTAL /0
COMPENSATION INSURANCE
('This section need not be completed if the permit is for one
Y❑ N�
Y N�
hundred dollars IS 100) or less I
I certify that 1n the performance of the work for which this per,
mit is issued, I shall not employ any person in any mminer so as to
OTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to the Workers' Compensation Laws of California.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
ALTER OR ADD TO MECH. 4.00
APPLIANCE 4.00
PLAN CHECK
emption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
FEE
AIR.HANDLING UNIT (TO 10=C.F.M.) 3.00
AIR HANDLING UNIT (OVER 10=C.F.M.) 5.00
SEISMIC FEE
-
CONSTRUCTION LENDING AGENCY
I hereby affirm that is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 2.00
the performance.of the work for which this permit is issued (Sec.
3097,CNC.). -
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
H EATI NG UNIT (OVER 100,000 B.T.U.)7.50
ELECTRIC
Lender's Name
Lender's Address
I certify that I have read this application and slate that the above
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
VENTILATION FAN (SINGLE) 3.00
PLUMBING
d C
/o
BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 4.00
BOILER -COMP (Over 100,000 BTUISEE FEESCH.
MECHANICAL
hereby authorize opresatlatives of this city to enter upon the
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD.
CON ST. .TAX
(We) agree to save, indemnify and keep harmless the City of
CupertI must Iinbili 'es, judgments, casts and expenses which
may ' a w a e against said City in consequence of the
PERMIT ISSUANCE 3.00
gra I th' -p
I"� I&
MECH. CONT. LIC. NO.
MECH.
OTAL
TOTAL
Si of roof r Date
OFFICE COPY