12835 APPLICANT TO FILL JN INFORMATION WITH IN'RED LINES - USE BALL POINT PEN ONLY
RU LDI NG PROJECT I DENTI F,ICATI ON PERMIT NUMBER
BUILDING .. APPLICATION & PERMIT a ����
AOORESS -I
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 1 ,
pWrvER'S. . ` PLAN CHECK VALIDATION
�l71 NAME CITY. 'ELECTRIC PERMIT, FEE
OSJ PHONE
y( rvnME nc*o'p4i R UTLETS-SWITCHES-RECEP 10.00/1.00 /0-
L
0-
' LIC...ela LIGHTING FIXTURES :10.00/1.00 C ,
\- CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00
7l ^DOREss ,fJ
PANELS r 10.00 DATE OF APPLICATION
ARCHI ECT - rs PANELS (OVER 200 AMP) 20.00 _ PLAN CHECK FEE P.C.NO. -
OR
ENGINEER
LIC,NO. - SIGNSTRANS. - 3.00
ARH,H,OR ENG.
ADDSPECIAL CIRCUIT 5.00
PERMIT VALIDATION
_ IIP rrEMP.METER ORPOLE INS. 20.00
APPLI rs
ADDRESS
i MOTORS FEE SCH. . .�
-
' SERVICE CHANGE .. 20.00
o i
F o O LICENSED CONTRACTORS DECLARATION
a u U I hereby affirm that I licensed under provisions of Chapter 9 ISSUANCE GATE
H < y (commencing with Sectionn 7000)of Division 3 of the Business and ,x^ BLDG.' ELECT. I PLG. MECH'
H D i Professions Code n y license is in full fur e n e e „"
-. 6 6 . .
Z o m License Class 1 Lic.Number_ ❑ ❑ ❑
0,, r o Date Contractor -
a u i J - BUIL NG PERMIT
li
TW -BUILDER DECLARKfION , . 'INFORMATION
w3: "- MISC.-. REFER TO'ORD -
; LL I- 1 hereby alfinn that I am exempt from the Contractor's'License VALUATION
Hu Oc Law for the following reason'(Sec.7031,5,Business and Professions PERMIT ISSUANCE 10.00 61- -
Code:Any city or county which requires a permit to construcl,alleq
a, --0,¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR, - LIC.NO. ELEC, p W
requires the applicant for such permit t0 file a signed statement that TOTAL 3 O PERMIT TO
' w$ he is licensed pursuant to the provisions of the Contractor's License `
Law(Chaplet 9(commencing with Section 7000)Of Division 3 ofthe ELCG�
a Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT =FEE
H$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
cg _ by any applicant for a povmt subjects ilia applicant to a civil penalty , ALTER-DRAIN -WATER (EA.) 5.00
- -
of not more than five hundred dollars(35001):
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 4.00 .00G GROUP' RES.UNITS
their sole compensation,-will do ilia work,and the structure is not -
intended Or Offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
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 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 idle,If,however,the building GAS-EA.SYSTEM-I1NC.40UTLETS 6.00
• or improvemenLis sold within one year of completion,ilia owner- IN
GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDG USE
builder will have the burden of'provmg that he did not build or im-
proveforpurposeofsaleJ. - INDUSTRIAL WASTE'INTER. 30.00 ' RES IND CON PB omer
❑ 1,as owner of thtr
e property.an,ex elusively conacting 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 Con awn'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 contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. ' TRACT NO, PARCEL NO.
❑ 1 dm exempt under Sec. " ,BAP.C.to,this WATER HEATER W/VENT 6.00 -
reason
Owner Date .r ,WATER SYSTEM 5.00
- ACC.DATE ACC:FILE N0.
WORKERS'COMPE-NSATION DECLARATION i WATER TREATING EQUIP. - - 5.00 ! -
I hereby affirm that I have a certificate of consent tp srlf-insure, rl es _I �a ill ,
Or a CCrtBlewe of Workers,CompeasaNnn Insurance,or a certified r ? ZONING ENG.SITE NO.
1 copy ihereof(Sec.3800.Lab,C.L o,5 [5T= 3'd-82
Policy No i Company ! J 66 -
O ❑ Certified copy is hereby furnished, VPL OK ', 4p'I , CG T - 34.0-7 FIRE SPRINK ENERGY T 24
Z 2• •❑ Certified copy is filed with the cityinspection division: t; - 'REFER.TO ORD.
Q APphcuot MI$C.' - Y ❑ N❑ Y ❑ N❑
CGRTIPICATII WORKERS' PERMIT ISSUANCE 10:00 FLOOD ZONE , A.L.U.C.
E EXEMPTION FROM -
W � COM11I'ENSATION INSURANCE PLG.CONTR. LIC.No. PLC.
CL 0 (This section need not be completed if the permit is for one TOTAL Y❑ N❑� Y EDN❑
Z) 2 hundreddollars(SI00)orless.)
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT ' FEE FEE SUMMARY
U.. I- mit is issued,I shall not employ any per n in n manner so as to
U become subjecpo lite Workers'frm�pa' lie -a f Culiborid. '
y Date)/7s�_ APPlicant[��f o ALTER OR ADD TO MECH. _ 5.00 .BUILDING
} to [).toPLAldic': If n" g is Certificum'ol i
F ? emptian,you should becohte subject In Ili .,kers'Co...pensm iox-
n APPLIANCE 5,00 - PLAN'CHECK
provisions of file Labor Code,"you.musl forthwith comply with .'FEE
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 10=C.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agancy,for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,CN.CJ. HEATING UNIT(TO 100,000 B.T.U.) ,8.00
Lender's Name t' HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certify that I have read this appfication 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 slate laws relating to building construction, and BOILER•COMP(3 H.P.or 100,000 B.T.U.).6.00
hereby authorise representatives of this city to ants, upon the BOILER-COMP love,100,0000TUl SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We)-agree,to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino.against liabiliti judgments, costs and expenses,which - CONST.TAX
may in 'n way ac u amst said City in consequc ce of he PERMIT ISSUANCE 10.00 -
gra go his porn t MECH.CONT. LIC.NO. - ' MECH.
2 '. TOTAL TOTAL '
a re of he / ontraclnrate - '
OFFICE COPY