3770 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
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BUILDING PROJECT I DENTIFICATION gppLICATION & PERMIT (�f�]O
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OWNED' PLAN CHECK VALIDATION
E (�/� DTV. ELECTRIC PERMIT FEE
. ob r o PHONE �Jlr�
NOMERncroRs ,,II OUTLETS-SWITCHES-RECEP 5.00/1.00
uc.No. AFI LIGHTING FIXTURES 5.00/1.00
ADDRESS
^ PPLIANCES-RESIDENTIAL 4.00
ADDRE55� / ,1�I N� 1 _�
PHONE IT/_�(% PANELS 6.00 GATE OF APPLICATION
OR
SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
uc.No. SIGNS TRANS. 3.00
AARCH.OR DDRESS ENG. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
IIP EMP.METER OR POLE INS. 15.00 n/f
APPucANTs MOTORS
ZSEE FEE SCH. ��O(
ADD ss
Q SERVICE CHANGE 10.00
. 02 LICENSED CONTRACTORS DECLARATION T(U
Q IZ W I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and n 4 n BLDG. ELECT. PLG. MECH.
H o i Professions Cod an my license is in full force up ef'ec 2 O'G /I f �- El El ❑
= License Class Lic.Number
z o L
H L w Dated Contractors 9lZ.L_ y'
Y rc ¢ OWNER-BUILDER DECLARATION !/1 -S I BUILDING PERMIT
rc w v INFORMATION
w ; y 1 hereby affirm that I am exempt from Lite Contractor's License MISC.- REFER TO ORD
H u O j Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00 /VALUATION $/FT.
I ,°> Code:Any City or county which requires permit to construct,alter,
lC 4 O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC. d('
wO LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
S he is licensed pursuant to the provisions of the Contractor's License
Hui
Law(Chapter 9(commencing with Section 70000of Division 3 oflhe
4 Business and Professions Code)or that he is exempt therefrom and OTT• PLUMBING PERMIT FEE JJ ih"-- IIILLL
mthe basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPUONSTR.
by any applicant for a permit subjects the applicant to a civil penalty n E
of not more than five hundred dollars(5500).): ALTER-DRAIN&VENT-WATER (EA.) 4.00 OC In
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00
their sole compensation,will do the work,and the structure is not
OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and ProfessionsDRAINS-FLOOR,ROOF,AREA,COND. 4.00 I
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 50.FT,FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
mentsare not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 1 NC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 9uILDING.0 SE
builder will have the burden of proving thus he did not build or im-
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 RES IND CDN PR Omer
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sea 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and 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 contractors)licensed pursuant In SEWER-SANITARY-STORM EA.200ft/8.00
the Can tractor's License Law. TRACT NO. PARCEL NO.
❑ I run exempt under Sec. .B.&P.C.tier this WATER HEATER W/VENT 4.00
rcusnn
Gare Owner WATER SYSTEM 4.00 ACC.DATE ACO.FILE NO.
W'ORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of cxmsent to soli'-insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or d certil'ieA
copy there�a(('��5�5�.�3100.Lab.C.).
Policy No.V+p_jJ;!$glarsNLA %_a_n lm 7yat� Twl-�
0 ❑ Certified cupyishurnb furnished. FIRE SPRINK ENERGY T 24
Z Z C Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
p Applicant Y ❑. N❑ Y ❑ N❑
CC Lo CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE XL.U.C.
W > COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
CL O (This section need noit t be completed if the permis for one TOTAL Y❑ N'❑ Y [:] N❑
D Z hundred dollars(4100)or less.)
U O I certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I. mit is issued,1 shall not employ any person in any manner So as to
U become subject to the Workers'Compensation Laws of California. Sa
LEI
Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
? emplion,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE f'
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
Lie performance of the work for which this permit is issued(Sec MICROFILM
3097,Civ.C.T HEATING UNIT(TO 100,000 B.T.U.) 4,00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)L50
Lender's Address ELECTRIC
I certify that l have read this application andslaty that the above VENTILATION FAN (SINGLE) 3.00
information is correct I agree to comply with all city and county PLUMBING
ondinunces and state laws relating to building construcllon, and BOILER-COMPI3 H.P.Dr 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP lover 100,000 B7ul SEE FEE SOH. 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, casts and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against said City in consequence of the
grant log f this permit h MECH.CONT. LIC.NO. MECH.
-bi /� _ TorAL TOTAL
Sign lu of mum Con [or Uute '
i OFFICE COPY