11780 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
- BUILDING PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
MA R %1 � o '� -BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 11780
xER'S PLAN CHECK VALIDATION
NAME CITY. ELECTRIC PERMIT FEE
'•j
J PHONE 5
coN RACTORs
OUTLETS SWITCHES
RECEP 10.00/1.00
NAME -
?
C UC.NO. 3(co LIGHTING FIXTURES 10.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
ADDRESS I'/^ �j
/ � �Vc PHONE 2,] (� PANELS 10,00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG. FERMI v N
ADDRESS SPECIAL CIRCUIT ,
ZIP TEMP.METER OR POLE INS. 20.00 F�II
APPLICANTS MOTORS SEE FEE SCH. Jr
ADDRESS
SERVICE CHANGE 20.00 t� Yti1111'
X
o till LICENSED CONTRACTORS DECLARATION
�I
a u U I hereby affirm that I um licensed under provisions of Chapter 9 ISSUANCE DATE
m <N (Commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. ME H.
H -0.z r0"Naons Code anJ y license is in(all force and of eC.� ❑ ❑ ❑
z o
P.
icense Class - Lic.Number_
4 r w
Contractor_
H 'n BUILDING PERMIT
I w J OWNER-BUIL DECLARATION INFORMATION
W O"' I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
g PERMIT ISSUANCE 10.00 VALUATION S/FT.
F;0 so,
Law for the following reason.(Sec.]031.5,Business and Professions
Code:Any city or county which requires a permit to construct,alter,
Q � Qp improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
O¢ requires[he applicant for such permit to file a signed slalmnent that TOTAL ER IT TO
¢ w m n he is licensed pursuant m the provisions of the Contractor's License
H z a
Law(Chapter 9(Commencing with Section 7000)of Division 3 of the /
s i D Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE NSTR
i3 � by any applicant for a permit subjects the applicant toe civil penally ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(55000.):
❑ 1,as owner of the property,or my employees with wages as BgCK FLOW PROTECT. DEVICE 4.00 o.C.GROUP RES.UNITS
their 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
Code: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 his own employees,provided that Such improve- GAS
or
6.00
ments are not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,file owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of Proving that he did not build or im- RES IND CON PB Other
/ prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ Cl ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCELNO.
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 far such projects with a contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT N0. PARCEL NO.
the Contractor's License Law.
❑ lam exempt under See, ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
/ WORKS RS'COMPF"NSATION D17CLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate ofcomenl to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(See.3800,Lab.CJ.
Po' Company
Q O Ce, tied Copy is hereby famished. FIRE SPRINK ENERGY T-24
Z Z }p Cert the is file 1, ygyJusp c'on division. MISC.- REFER TO ORD. Y ❑ N❑ Y❑ N❑
FApplica Lyses
CERTIFICATE OF EXEMPTION 17ROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZorvE A.L.0 c.
W - 'COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG. Y❑ N❑ v❑ N❑
c
CL O (This section need not be completed it' the permit is form TOTAL
D Z hundred dollars IS 100)or len.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mil is issued,1 shall not employ any person in any manner so as to r
Ow become subject to the Workers'Compensation Laws of California. _ BUILDING
Dale Applicant ALTER OR ADD TO MECH. 5.00
} tad NOTICE TO APPLICANT: if,after making this Certificate of E.
? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply will FEE
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10)]OOC.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 agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certify that I have twit this application and slate that the above VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city and county gOILE COMP 13 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws totaling to building construction, and
hereby ao cirue representatives of this city to enter upon the BOILER-COMP(Over l00,000BTU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indeamify 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 against said City in Consequence of the PERMIT ISSUANCE 10.00
I this pel. y MECH.CONT. LIC.NO. MECH.
n, . 4 .i ki rj OG TOTn} TOTAL
nature ofAppThcanl/Contractor Date
OFFICE COPY