12208 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
APPLICATION & PERMIT
BUILDING
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OWNER'S PLAN CHECK VALIDATION
OTY. .. ELECTRIC PERMIT FEE
PHONE
CONTRACTORS
NAIVE UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
LIGHTING FIXTURES 10.00/1.00
cONTRACTOR'E PPLIANCES-RESIDENTIAL 4.00
PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
E�Racya�
vyCL_l 5J v 4K:.No. SIGNS TRANS. 3.00
ARCH.OR ENG, SPECIALCIRCUIT 5.00 PERMIT VALIDATION
SS
ZIP TEMP.METER OR POLE INS. 20.00
APPUCANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE
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-02 LICENSED CONTRACTORS DECLARATION
a u I hereby affirm that I am licensed under provisions of Chapter 9 ftSSUANCE DATE
y "' (commencin with Section 7000)of Division 3 of the Business and
¢ u g LECs. PL❑G. MECH.
r N i Professions Code,yp y license is in full for
zo,n - Licens ass Lic.Number
o Dale Contractor
a Y E ILDING PERMIT
cc w u OWNER-BUILDER DECLARATION INFORMATION
w ;LL I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
�i VALUATION $/FT.
u0a Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00
w w Code:Any city or county which requires a permit to construct,alter, 7
ar ¢ ¢ O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. �S {U __V
i w m u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
he is Chapte pursuant en ingprovisecti of the Contractor's License
r z i Law(Cha ter9(commencin with Section 7000 of Division3of the
4 c Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
¢ H the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant loacivilpenalty gLTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITStheir 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. 5.00
Codes The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES,PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through Itis own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 REB IND CON PB Omar
❑ I,as owner of the properly,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 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 contraetnr(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ I am exempt under SCE.-,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date - WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate ofconsent to self-insure, ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(See.3800,Lab.C.I
Policy No. Company /�L'-'Mn�/,f V'�/�
0 ❑ Certified Opyy is,hetelry fyuysh. FIRE SPRINK ENERGY T-24
Z ZI � ❑ Certiri c Py I t wI ne city inspection division.
01/ Applicant/ /-_ MISC.- REFER TO ORD. Y ❑ N[] Y ❑ N❑
~ rn i PERMIT ISSUANCE 10.00
cc - CERTIFICATE F EXEMPTION FROM WORKERS' VI
ZONE A.L.O.C.
Lu > COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
CL 0 '(This Section need not be completed if the permit is for one TOTAL V❑ N❑ Y❑ N❑
Inndred dollars IS 100)or less.)
L) O 1 certify that in the performance of the work for which this per, CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,[-shall not employ any person in any manner so as to
0w become subject to the Workers'Compensation Laws of California
CL Dale Al Pl'cant ALTER OR ADD TO MECH. 5.00 BUILDING 7 Q S�
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F ? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of tie Labor Code, you must forthwith comply with FEE
V 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.EM.) 6.00 SEISMIC FEE ,Z
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.C.). s HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct.I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP IGVer 100,000 BTU)SEE FEE$CM. 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 i an way c gainst said c�� � PERMIT ISSUANCE 10.00' gran ' go th' p ml' MECH.CONT. LIC.NO. MECH.TOTALTOTALSig are of Ap icant/ OntraotO, -
OFFICE COPY '