4875APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
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BUILDINGPRO,, IDENTIFIC! N APPLICATION & PE IT
BUILDING
ADDRESS
E L BUILDING -ELECTRICAL -PLUMBING -MECHANICAL
OwNER'a -Y.' PLAN
NAME GTV. ELECTRIC.PERMIT FEE
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NAM
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ENGINEER
C o O
LICENSED CONTRACTORS DECLARATION
AL CIRCUIT
I hereby affirm that I am licensed under provisions of Chapter 9
a A,(commencing
with Section 7000) of Division 3 of the Business and
us
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Professions Code, and my license is in full force and effect.
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License Class Lic. Number
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Date Contractor
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NOTICE TO APPLICANT: IL after making this Certificate of Ex.
emption, you should become subject to the Workers Compensation
provisions of the Labor Code, you must forthwith comply will,
such provisions or this permit shall be deemed revoked.
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OWNER -BUILDER DECLARATION
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1 hereby affirm that I am exempt from the Contractors License
4
Law for the following reason. (Sec. 7031.5, Businessand Professions
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ay
Code: Any city or county which requires a penni(to construct. alter.
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improve, demolish, or repair any structure, prior to its issuance, also EI
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requires the applicant for such permit to file a signed statement that
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he is licensed pursuant to the provisions of the Contractor's License
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La..(Chapter 9(commencing with Section 7000) of Division 3 of the '
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Business and Professions Code) or that he is exempt therefrom and CI
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the basis for the alleged exemption. Any violation of Section 7031.5
lects the too civil penalty
cant for ahundred
llars ($500).cant
of not more than five doermit
I certify that I have read this application and state that the above
❑ 1, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
.
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
_
properly who builds or improves thereon, and who does such work
- _1.y
himself or through his own employees, provided that such improve-
....
sp
ments 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 he did not build or im-
prove for purpose of sale.).
MECF
❑ 1, as owner of the property, am exclusively contracting with
granting of this permit I
licensed contractors 1. construct the pfoject (Sec. 7044, Business
and Professions Code: The Contractor's License Law docs not apply
to an owner of property who builds or improves thereon. and who
contracts for such projects with a contractor(s) licensed pursuant to
the Contractors License Law.
❑ 1 am exempt under Sec. . B.&P.C. for this
reason
Date Owner
WORAERS'COMPENSATION DECLARATION
I hereby effort that 1 have a certificate of consent to self-insurt.
or a certificate of Workers' Compensation Insurance, or a certified
copy thereof(See. 3800, Lab.G).
Policy No. Company
❑ Certified copy is hereby furnished.
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❑ Certified copy is filed with the city inspection division.
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Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS'
AL CIRCUIT
5.00
METER OR POLE INS.
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COMPENSATION INSURANCE PLG.0
1 O
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V O
LL F
O W
(This section need not be completed if the permit is for one
hundred dollars (S 100) or less.)
I certify that in the performance of the work for which this Per- CITY
mit is issued, I shall not employ any person in any manner so as to
become subject to the Workers' Compensation Laws of California.
Date Applicant
10.00
20.00
LAWN SPRINKLERS - 1 INC 5 V.B.
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2
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NOTICE TO APPLICANT: IL after making this Certificate of Ex.
emption, you should become subject to the Workers Compensation
provisions of the Labor Code, you must forthwith comply will,
such provisions or this permit shall be deemed revoked.
1.00
SEWER -SANITARY -STORM EA. 200ft/8.00
WATER HEATER W/VENT
4.00
CONSTRUCTION LENDING AGENCY
4.00
WATER TREATING EQUIP,
I hereby affirm that there is a construction lending agency for
the performance of the work for which this Permit is issued (Sec.
3097, Civ.C.).
Lender's Name
Lender's Address
I certify that I have read this application and state that the above
information is correct. 1 agree to comply with all city and county
.
ordinances and state laws relating to building construction. and
hereby authorize representatives of this city to enter upon the
_
above-mentioned property for inspection purposes.
(We) agree to Save, indemnify and keep harmless the Cit)' of
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue against mid City in consequence of the
MECF
granting of this permit I
"LETS -SWITCHES -RECEP 5.00/1.00
HTING FIXTURES 5.00/1.00
LIANCES- RESIDENTIAL 4.00
I TRANS.
3.00
AL CIRCUIT
5.00
METER OR POLE INS.
15.00
IRS
SEE FEE SCH.
IrP rwAmr.F
10.00
R
ELEC.
TOTAL
r;- PLUMBING PERMIT. .'FEE
LTER-DRAIN & VENT -WATER (EA.) 4.00
BACK FLOW PROTECT. DEVICE
2.00
DRAINS -FLOOR, ROOF, AREA,COND.
4.00
FIXTURES - PER TRAP
4.00
GAS-EA.SYSTEM-I1NC.40UTLETS 4,00
GAS - EA. SYSTEM - OVER 4(EA.)
1.00
INDUSTRIAL WASTE INTER.
20.00
LAWN SPRINKLERS - 1 INC 5 V.B.
5.00
LAWN SPRINKLERS -OVER 5 (EA.)
1.00
SEWER -SANITARY -STORM EA. 200ft/8.00
WATER HEATER W/VENT
4.00
WATER SYSTEM
4.00
WATER TREATING EQUIP,
4.00
MISC.- REFER TO ORD.I
PERMIT ISSUANCE 6.00
)NTH. LIC. NO. PLG.
TOTAL
MECHANICAL PERMIT
ALTER OR ADD TO MECH. 4.00
APPLIANCE 4.00
AIR HANDLING UNIT (TO 10,000C.F.M.) 3.00
AIR HANDLING UNIT (OVER 10p00C.F.M.) 5.00
EXHAUST HOOD (WITH DUCT) 2.00
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATING UNIT (OVER 100,000 B.T.U.)7.50
VENTILATION FAN (SINGLE) 3.00
BOILER- COMP (3 H.P. or 100,000 B.T.U.) 4.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MISC. - REFER TO ORD.
PERMIT ISSUANCE 3.00
OFFICE COPY
FEE
4875
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FEE SUMMARY
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PLAN CHECK
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SEISMIC FEE
MICROFILM
ELECTRIC
PLUMBING
MECHANICAL
CONST. TAX