5780 i L e
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES = USE BALL POINT PEN ONLY
` BUILDING PROJECT�hDENTI FICA710N . ' .PERMIT NUMBER
y. BUILDINGAPPLICATION & PERMIT
Vo UILDINGELECTRICAL—PLUMBING—MECHANICALBv 5780
0 NER'a
NAME d7 PLAN CHECK VALIDATION
GTY. ELECTRIC PERMIT FEE
lvl NAME NE
corvTRAcrORs C.cJgfYoI ;' —OUTLETS-SWITCHES-RECEP 5.00/1.00
LIC.No. S S' LIGHTING FIXTURES '.tl5.00/1.00
nooses TORS HIS" r APPLIANCES-RESIDENTIAL-r 4.00 '
/ 1 Q PHONE PANELS S.00 DATE OF APPLICATION
ARCHITECT s - PLAN CHECK FEE P.C.NO.
OR' - SIGNS "6.00 ' -
ENGINEER I –LIC, ..
• c.No''. - ` SIGNS TRANS. � 3.00 '
moo ESSS Ervc. SPECIAL CIRCUIT .5.00 PERMIT VALIDATION
e ZIP EMP.METER OR_POLE INS. '� 15.00.
APPLICANTS s - MOTORS. , SEE FEE SCH.
A
SERVICE CHANGE - 10.00
w o o LICENSED CONTRACTORS DECLARATION •
iW I hereby affirm that I am licensed under provisions o('Chapter 9 ' ISSUANCE DATE.'
¢u (commencing with Section 7000)of Division 3 of the Business and I BLDG- ELECT. PLG. NIECE.
H ? Professions,}sCode nd m ansa Din full fort and effect.
zou"i Daenw�Clu S;�Lic.Nutoroll� - �', El ❑
m r w Date /L Contractor -
¢ m E GarytlU� .. BUILDING PERMIT
¢ ¢¢ OWNER-BUILDERIDECL'ARATIOhk
w o : - INFORMATION
w ;LL y I hereby affirm that I am exempt from,the Contractor's License 1 MISC, '.REFER TO OR
HLLoa Law for.the following reason. 703 t.5,Businessand Professions s.PERMIT ISSUANCE VALUATION '$/FT.'
Code Any city or county which requires a permit to construct,alter, 6.00 leen .-
2 40 impr demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. •,a LIC NO.- ELEC. A
u wO u requires the applicant for such permit to file a signed statement that .� - . TOTAL - PERMIT.TO
$ he is licensed pursuant to the provisions of the Contractor's License r �'
w. Law(Chapter 9(commencing with Section 7000)of Division 3 of the y
Business'and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT I�E@f
rc= $ the basis for the alleged exemption.Any violation of$ection 7031.5 _ STORIESTYPE CONSTR.
a,; by any applicant for a permit subjects the applicant to a civil penalty + gLTER-DRAIN&'VENT-WATER (EA.) 4.00
-
of not more than five hundred dollars($5001) ` - -
❑ I,as owner of the property,or my employees with s wages as . ,p'+BA'CK'F.LOWIPROTECT. DEVICE 2,00 oce.GROUP- RES UNITS
FLOW -
their ile'compensation,will do the work,and the structure is not -
intended or offered for sale(Sec. 7044, Business and.Professions DRAINS,�FLOOR,IROOFrPAREA,COND. 4.00 t ,
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_. 4.00 SO.FT:FLOOR AREA TOTAL ACREAGE
. himself or through his own employees,provided that such impro a
m ,r„ - -
ems are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM 1'INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner, GAS-EA.SYSTEM-OVER 41EA.) 1.00 . BUILDING uSE
builder.will have the burden of proving that he did dot build or im- - .. RES.. IND. CON PB Other
prove for purpose of saleJ. INDUSTRIALW ASTE•I NTER. 20.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors' to construct the projecC(Sec.7044,Business LAWN SPRINKLERS-1 1NC 5 V.B. -5.00 ASSESSORS PARCEL NO.
and Professions Cade:The Contractor's License Law does not apply _ '•""" -
to an..net of property who builds or improves thereon,and who LAW_N'S_PRINKLERS-OVER 5'IEA.K 1.00
' contracts for suet)projects with a contractors)licensed pursuant Io -
theContractor'sLicenseLaw. SEWER-SANITARY:-STORM" EA.200ft/8.00 TRACT NO. PARCELNO.
-
❑ I am exempt under Sec.—:B.&P.C.forth"
WATER,.HEATER W/VENT, '4.00 1"
reason
Owner 'Date WATER SVSTEM� 4.00 ACC.DATE 'AGE.FILE No.,
WORKERS'COMPENSATION'DECLARATION WATER'TREATING EQUIP, I 4.00
1 hereby affirm that I have.a certificate of consent to self-insure, r " -
or a certificate of Workers'Compensation'nsurance or a certified ZONING ENG.SITE NO.
copy there f Sm
cc 3800;Leh C) *i
Policy No pany fir I I=A
(] ❑ Certified copy is hereby funushed. FIRE SPRINK ENERGY T Y4-'
z 1)( Certified copy is filed with the city inspection divislOn,' ,a-
-O ApPlicam t MISC.'-,:. •`,;:. . .,.REFER TO ORD. v❑ N❑ r❑ N❑.
~ rn PERMIT ISSUANCE, 6.00 "f,.+ r•'
CC > CERTIFICATE OF EXEMPTION FROM WORKERSA.L.0 c.
'`
FLOOD zorvE
LU _ COMPENSATION INSURANCE - PLG.CONTR. n
'd (This section need nut be completed if the permit-is for one ' " TOTAL Y❑ N'❑ Y❑ N❑
z hundred dollars($100)or less.) ' I "
U O I certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
U_ mit is issued;1 shall not employ any person in any,manner an as to
U become subject to the Workers'Compensation Laws of California. _ h
W Dato 'Applicant i" ' ALTER OR ADD TO 4,00 BUILDING'
} In NOTICE TO APPLICANT: If,after making this Certificate of Ex-
emption,
x - - '
♦— Z emption,you should become subject to the Workers.Compensation' APPLIANCE 4.00 .PLAN CHECK,
provisions of the Labor Code, you must forthwith.eomply with FEE
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MOCF.M.) 3.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER IOMC.F.M.) 5.00 . SEISMIC FEE 1(
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which,this permit is issued(Sec. .MICROFILM ,
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T:U.)- 4.00
Lenders Name HEATI NG UNIT(OVER 100,000 B.T.U.P.50 ELECTRIC
Lender's Address
1 certify that I'have read this application and state that the above VENTILATION"FAN'(SINGLE) 3.00 '
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.) 4.00 . ,
hereby authorize'representatives of this city to enter upon.the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICA Lj•
above-mentioned properly 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 whichCONST.TAX
may in any way,accrue against said City in consequence of the PERMIT ISSUANCE 3.00
gmn ing of this ermit.. MECH.CONT. LIC.N0. - MECH.
�' TOTAL• TOTAL (04
. •` -
SignaureofApplicant/Contractor Vile
OFFICE COPY ,