17686 (2) rAPPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
t
- BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT
PERMIT NUMBER
BU DING
,. 4 17686
Cr G BUILDING - ELECTRICAL-PLUMBING-MECHANICAL ,-
SOWN R'S y0� PLAN CHECK VALIDATION
NA. _ O QTY. ELECTRIC PERMIT FEE
PNON -
tk
CC TRACT R'6
NA A. S' s0 OUTLETS-SWITCHES-RECEP 10,00/1.00 a 0
Q Lr Lc. D. LIGHTING FIXTURES 10,00/1.00
ADD.ess oR's S' APPLIANCES-RESIDENTIAL 4.00 40fl -
Si!f PR.NEF/ t-? PANELS - 10.00 DATE OF APPLICATION '
- A - CiTI
, PLAN CHECK FEE P.C.NO.,
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.No. SIGNS TRANS. 3.00
AARCH,OR DDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
' ZIP EMP.METER OR POLE INS. 20.00 1 �
APPLICANTS - MOTORS SEE FEE SCH.
AODRE6a _ •� '
Lreaoj
SERVICE CHANGE Pfl E) 20.00 `,L i ICl l
w 0 2 LICENSED CONTRACTORS DECLARATION s t V\ V `l
a u u I hereby affirm that I am licensed under provisions of ChaPter 9 . ISSUANCE DATE '
vHi Q n (commencing all Section 7000)of Division 3 of the Business and - BLDG. ELECT. PLG. MECH.
r D i Professions Code,and my license is in full force and effect. .,
o Z o License Claas Lia Number
F J Date Contractor City ofCupQrtloo `
BUILDING PERMIT
a ¢wOWNER-BUILDER DECLARATION INFORMATION
wD e- I- I hereby affsrm.that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
3 LL VALUATION $/FT.
F u w J Law for the following reason.(Sec.703 1.5,Business and Professions PERMIT ISSUANCE .10.00 Z0
m0 Cade:Any city or county whichrequiresa permit toconstruct,alter,
¢ ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
D o requires the applicant for such permit to file a signed statement that TOTAL (��V V PE I TO
a w m be'is licensed pursuant to the provisions of the Contractor's License
r z a
Law(Chapter 9(commencing with Section 7000)nf Division 3 ofthe
Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
¢E$ the basis for the alleged exemption.Any violation of Section 7031.5 -STORIEt rTYPECONSTR.
by any applicant for a permit subjects the applicant to a civil penally
ofno1morethanfivehundreddoilars(5500).): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ 1,as owner of the properly,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCD.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,AR EA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
¢f gn' propertywho builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SQ FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
r
line is are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.40UTLETS 6.00 -
or improvement is said within one year of completion,the owner- Q BUILDING USE
I 4 builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4(EA.) 2.00
Prove for purpose crate.), INDUSTRIAL WASTE INTER. 30.00 RES IND CON PS Other,
) ❑ I,a6 owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ .❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC5 V.B. _ 6.00 - ASSESSORS PARCEL No.
End Professions Code: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 for such projects with a commCIORS)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec.�,BAPC.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 of consent to self-insure, s
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy tBelSpfj$ 0,Lab.CJ. .
PolicYCCyyf�/lZSI/ mpany -
O ❑ erll copy is hereby furnished. FIRESPRINK ENERGYT-24
Z Z ❑ Cerci' copy is d��svl}h�t�a city inspection'division. -
O Alm urn '� -/i'�-4. MISC.- REFER 700RD. >> Y❑ N Y ❑ N❑
� W CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 VO FLOOD ZONE A.L.U,C.
LL �_ ' . COMPENSATION INSURANCE PLG.CONT R. LIC.NO. PLG.
Y DO
N
D' 0 (This section need not be completed if the permit is for one TOTAL ❑ ❑ Y [:] N❑
=) Z hundred dollars(S 100)or less.)
L) O 1 certify that in the performance of the work for which this per- FEE SUMMARY
LL F mil is issued,I shall not employ any person in any manner so as to
U become subject to the Workers Compensation Laws of California.
LU Date Applicant ALTER OR ADD TO MECH. 5.00 rELECTRIC
} W NOTICE 1'0 APPLICANT: If,after making this Certificate of Ex-
� ? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00
provisions of the Labor Code, you must forthwith comply with
C„7 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 „ -
30e .CivCance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT 100,000 B.T.U.)9.50 Lender's Addressi
to 'I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
ti. information is correct.I agree to comply with all city and county -PLUMBING r QD
- oidimnces and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hireby authorize representatives of.this city to enter upon the
P above-mentioned property for inspection purposes. BOILER-COM P(Over 100,0011 BTU)SEE FEE SCH. MECHANICAL
,(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 any way accrue against mid City in cousequen e of the PERMIT ISSUANCE 10.00
g of This pe mit. MECH.CONT. LIC.NO. MECH
/S-1 TOTAL $,
gnature of AfflircantiContracon rDate
OFFICE COPY