8205 APPLICANT TO FILL IN INFO ATION WITHIN RED LINES - USE L POINT PEN ONLY
~ 'BUILDING PROJECT I DENTIFICAW PERMIT NUMBER
aUILGING APPLICATION & PERMIT O
AOORESa
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
owNL 's
NAME A PLAN CHECK VALIDATION
DTV. ELECTRIC PERMIT FEE
F PHON7
CONTRA TOO
sPTsai„A,q„r,_ UTLETS-SWITCHES-RECEP 10.00/1.00
LBK eA14P UC.No Z/ ILIGHTING FIXTURES 10.00/1.00
ADDRESS TORS �� PPLIANCES-RESIDENTIAL 4.00
4i 4446&a f, E f 6727 PANELS 10.00 DATE OF APPLICATION
09CHrtEPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
1 LIC.No, SIGNS TRANS. 3.00
ADDRRESS ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
Doo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
ri w 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
< u (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r y i Professions Cod and m license is in full fort of e t - ss..�t� ❑ ❑ ❑
Z. i w W License Class Con Number }uJ
Dale�.y
Contractor
UI ING PERMIT
r ¢ i OWNER-BUILDER DECLARATION A xl RMATION
wN 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD _ `
n o or Law for the following reason.(Sec.7031.5.Business and Professions VALUATION $/FT.
- PERMIT ISSUANCE 10.00
Code:Any city or county which requirese permit to construct,alter,
Q FO improve,demolish,or repair any structure,prior m its issuance,also ELEC.LDNTR, LIC.NO. ELEC.
K D LL requires the applicant for such permit to file a signed statement that TOTAL u Ep
se$ he is licensed pursuant to the provisions of the Contractor's License a► ` T�0��b
F Z i Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe �r
F 2 o Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE b�
as- 0 the basis for the alleged exemption.Any violation ofSection 7031.5 SORIES TYPE CONSTR.
i 3 by any applicant for a pionnt subjects the applicant to a civil penalty ,
of not more than five hundred dollars($5000.) ALTER-DRAIN&VENT-WATER (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 sl ructure is not OCC.GROUP RES.UNITS
intended or offered for sale(Sec. 7044, Business and PmfessiansDRAINS-FLOOR,ROOF,AREA,EA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 SG.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve.
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner - . - . .00- GAS EASYSTEM OVER 4 IEA) 2
builder will have the burden of proving that he did not hurt(]or im- BUILDING USE
.prove for purpose the
RES IND CON Pe Other
of eJ' INDUSTRIAL WASTE INTER. 30.00 1:1El
❑ as owner of the property, exclusively contracting with
licensedd contractors to construct the
project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 g55E550 SPARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of properly who builds tr improves used uand who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft 10.00
the Contractors License Law. / TRACT NO. PARCEL NO.
❑ lam exempt under Sec..,BAP.C.for this
reason WATER HEATER W/VENT 6.00
Owner Data WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm [hat I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or ert'fi ate f Wo a Compens n Insuranceyr�certified
Pohl o. C npany�=
❑ Cer copy lsh h rntshcd. FIRE SPq INK 'ENERGY TQa
Z Z ❑ Ce ifie Fo t s th m ti division.
e �Jt, t MISC.- REFER TO ORD.
O Applic in V N� V N�
Fy PERMIT ISSUANCE 10.00 FLOODZONE A.LU.C.
Lu :RTI PICATE E EATIOTINS FROM WORKERS'
W � COMPENSATION INSURANCE PLG.coNrR. LIC.No., PLG.
CLZ (This section need not be completed if the permit is for one TOTAL Y❑ N Y E] N
UO hundred dollars I S 100)or less.)
1 certify that in the performance of the work for which this per, CITY. MECHANICAL PERMIT FEE FEE SUMMARY
IL H ,mit is issued,I shall not employ any person in any manner so as to
0 U hecomesubject to the Workers'Compensation Laws of California. �pN
i Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} 0 NOTICE TO APPLICANT: If,after making[his Certificate of lix-
F2 caption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK Q
provisions of the Labor Code, you must forthwith comply with FEE /O �A
U 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 I0MC.F.M.) 6.00 SEISMIC FEE 3a�
I 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.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
LenderAddress
HEATI NO UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and state[hat the above VENTILATION FAN (SINGLE) 4.00
ordinances
n correct I agree to comply with all city and county PLUMBING
o ormatio and stale laws relating to comply
buildi wit, construction, m, BOILER-COMP I3 H.P.Or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city [o enter upon the BOILER-COMP (Over 100,000 BTUI 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 again Said City in consequence of the PERMIT ISSUANCE 10.00
gr is MECH.CONT. LIC.NO. MECH.
X-17-85- TOTAL TOTAL
store of Applicant/Contractor Date
OFFICE COPY /