0485 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN OOVW
BU I LDING PROJECT I DENTIFICAT T IV ERMIT'NUMBER
'
BUILDING APPLICATION & PERT 0 485
BOORE
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
PLAN CHECK VALIDATION
NAME
DTV. ELECTRIC PERMIT FEE
PHONE
NAMERacroRs UTLETS-SWITCHES-RECEP 5.00/1.00
- LIC.No, LIGHTING FIXTURES`„ 5.00/1.00
CONTRACTORS -
;
ADDRESS
- APPLIANCES-RESIDENTIAL 4.00
CO
PHONE PANELS / 5.00 DATE OF APPLICATION
PORRCHITECT SIGNS L 6.OD PLAN CHECK FEE P.C.NO.
ENGINEER
' LIC NO, SIGNS TRANS. T 3.00
ARCH.OR ENG. S.00 PERMIT VALIDATION
ADDRESS SPECIAL CI_FCUIT_as AL
ZIP TEMP.METW OR LE 15.00 �
APPLICANT'S .• MOTORS ! EE FEE SCH. vJ/`6�1•/(
ADDRESS
SERVICE CH GE O 10.00
o o LICENSED CONTRACTORS DECLARATION
a.A, 1-hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y a H (commencing with Section 7000)of Division 3 of the Business and B ELECT. PLG.. MECH.
t D z Professions Code,and my license is in full force and effect. ❑ ❑ ❑
o i w o License Class Lie.Number'
Date Co not,m,
a 2 d BUILDING PERMIT
>< a ¢ OWNER-BUILDER DECLARATION
Ix o a.D MISC.- REFER TO ORD INFORMATION
w ; I- I hereby affirm that I am exempt from the Contractor's License
u o g Law fur the following reason.(Sea 7031.5,Bus'aas and Professions PERMIT ISSUANCE vALuanoN
H _ 6.00 00
Code:Any city Dreamily which requires a permit to construct,alteq
rt rt > improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
i O u requires the applicant for such permit to file a signed statement that TOTAL URMIT TO
w $x he is licensed pursuant en the provisions of the Contractor's License �g..a.. S.lLD �a�
ca I> Law(Chapter 9(commencing with Section 7000)of Division3 of the (,(, w h//
a Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
X L. the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TVpE CONSTR.
A. by any applicant fora permit subjects the applicant roacivil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(5500).): -
❑ 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 or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 -
Code:The Cmametor's License Law Coes 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 TOTAL ACREAGE
• himself re through his own employees,provided that such improve-
ments
buildi e-
menton not throuhh is oroffered employeesale.Iided but
suhebmlding GAS-EA.SVSTEM•11NC.40UTLETS 4.00
Cr improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Orbe
provefor Purpose ofsale.). INDUSTRIAL WASTE INTER. 20.00 ❑. ❑ ❑ ❑ ❑ '
❑ 1,as owner of the property,am exclusively contracting with
licensed contractors to constructthe project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Cade:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts forsuch projects with a contractGr(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am olemplunder SeC. -,B.&P.C.for this WATER HEATER W/VENT - 4.00
!'Season
Date_ Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DIi LARATION WATER TREATING EQUIP. 4.00
1 hereby affum that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. - Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z ❑ Certified copy is filed with tire"city inspection division. - REF ER TO ORD.MISC.
O Applicant V❑ NEIY [:] N[]p: rn - PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.0 C.
CERTIFICATE OF EXEMPTION FROM WORKERS'
.JU COMPF-NSATION INSURANCE PLG.CONTR. LIC.NO. PLO, y F] N❑' Y [3 N❑
1 O ('(his section need not be completed if the permit is for one TOTAL
� Z hundred dollars IS 100)or less.l
U O 1 certify that in lire performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
UL H mit is issued,I shall not employ any person in any manner sn as to
U become subject to the Workers'Compensatimr Lows of Calimmie.
I Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING /Qr Q'Q
} N NOTICE TO APPLICANT: If,after making this Certit'icate of Ex.
F ? emption,you should become subject to the Workers'Conammiation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code.you must forthwith comNy'will FEE sa
U such provisions or this permit shall be deented revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000C.F.M.) 5.00 SEISMIC FEE 4�
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
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.17.50 ELECTRIC
1 certify that I have read this application and state that Ore above VENTILATION FAN (SINGLE) 3.00
• information is correct. I agree to comply with all city and county PLUMBING
BOILER-COMP I3 H.P.or 100,000 B.T.U.1 4.00
ordinances and state laws relating to building construction, and
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 Too
O ORD,
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in anyway accrue against said City in comequence of the PERMIT ISSUANCE 3.00
grant, of tills permit. MECH.CONT. LIC.NO. MECH. M'
(p 15
TOTAL TOTAL 17 V_
Si at o Applicru Contractor Date
OFFICE COPY