5870 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT'IDENTIFICATION
PERMIT NUMBER
BUILDING ` APPLICATION & PERMIT
AOOn E55
OLiq% NEVI K BUILDING- ELECTRICAL-PLUMBING -MECHANICAL 5870
OWNER'S PLAN CHECK VALIDATION
NAME TY. ELECTRIC PERMIT FEE
Ro PHONE
NAMERAcronx UTLETS-SWITCHES-RECEP 5.00/1.00
�• T I LIC.No. 'JO LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S
ao 'PPLIANCES-RESIDENTIAL 4.00
oREss
ll8' y L 0<+ �f9 PHONE / p^3II PANELS 5.00 DATE OF APPLICATION
OPRCNITECT SIGNS 6.00 PLAN CHECK P.C.NO.
ENGINEER LIC.NO, SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION -
ADDRESS, SPECIAL CIRCUIT 5.00
l
ZIP EMP.METER OR POLE INS. 15.00
AppucnNT's ADDRESS MOTORS SEE FEE SCH, n/1
SERVICE CHANGE 10.00
w o o LICENSED CONTRACTORS DECLARATION
a vw I hereby affirm thin I am licensed under provisions of Chapter 9 z r ISSUANCE DATE
I- a, (commencing with Section 70001 of Division 3 of the Business and
y a,NA L ELECT. PLG. MECH.
r N Z Professions Coed-s�-yn� 'cense is in full fureq app ejfcpj.
O,n - License C ss 1. Lic.Number_1\�ny'�iie�E-1
9 w D Dalc O- ContolCum�
a r. UILDINQ PERMIT
a OWNER-BUILDER DECLARATION
a o s v INFORMATION
X ;LL r 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
w V UATION $/FT.
u o J Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 6.00
ve Code:Any city or county which requires a permit to construct,alter, O�
Q p ¢ improve,demolish,Or rehab any Structure,prior IO IIS IsellanCC,aI50 ELEC.CONTR. LIC.NO. ELEC.
aO u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w m he is licensed pursuant to the provisions of the Contractor's License
r z as Low(Chapter 9(commencing with Section 7000)of Divisions 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE ZZ//
¢.: $ the basis for the alleged exemption.Any violation of-Section 7031.5 STORIES TYPE CONSTR.
a3 � by any applicant for a permit subjects the applicant loa civil penally ALTER-DRAIN (EA.) 4.00
of not more(ban five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 0 C GHOUR REJ.UNIT
their pile compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7144, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves[hereon,and who does such work FIXTURES-PER TRAP 4.00 g0,F .FLOO ARE TOTAL ACREAGE
. ...Cuts re not intgh ended
ownemployees,for sale.
If,ed ever,hat the
improve- GAS-EA.SYSTEM-1 4.00
mems are not intended or offered for sale.If,however,the building
In improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder,will have the burden of proving That he did not build or ion- ES IND CON PB Oder
prove foreof sale.(. INDUSTRIAL WASTE INTER. 20.00
❑ 1,ass owner
of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's Li se Law does not apply
to an owner of property who buil Improves[hereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects w' mb[ractor(s)licenud pursuant to SEWER-SANITARY-STORM EA.200f1/5.00 TRACT NO. PARCEL NO,
the Contractor's Licens w.
❑ lam oxen or Sec.-,BAP.C.for his WATER HEATER W/VENT 4.00
reason
Owner ac Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 herehy affirm that I have a car' a of consent to self-insure' ZONING ENG.SITE NO.
or a certificate of Workers'C nsalion Insurance,or a certil icd
copy thercof(SeL.3800, C.).
Policy No.
IT
❑ Certified as is hereby furnished. FIRE SPRINK ENERGY T-24
z ❑ Cerlifie opy is filed with the city inspection division,
O MISC. REFER TO ORD. ❑ ❑ ❑ ❑
AppliCCer V N V N
Fy PERMIT ISSUANCE 6.00 FLOODZONE A.L.U.C.
LU CERTIFICATE PE EXEMPTION FROM WORKERS'
W 7 COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. •
Z (This section need not be compleled if the permit is TP
r-one TOTAL V F] NEI Y C] N❑
hundred dollars IS 100)or less.)
L) O I certify that in the performance of the work for which this pen QTY. MECHANICAL PERMIT FEE FEESUMMARY
LL 1- mil is issued,I shall not employ any person in any nomper So as to
O W beco •sub'ec1, t e Workerli s tiprq{on Law'Of alit
y Dam APPlicunl- a ALTER OR ADD TO MECH. 4.00 BUILDING
} In NOTICE TO APPLICANT: If,after making this Certiticme of ox-
Z emption,you should become subject to tam Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply witLh FEE
U such provisions or(his permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=r-F.M.) 3.00
CONSTRUCfION ENn CAGENCY AIR HANDLING UNIT(OVER I0,000C.F.M.) 5.00 SEISMIC FEE
-
1 hereby affirm that there ie nstruclion lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance the coo or which this permit is issued(Sec - MICROFILM
3097,Civ.C.I HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name -- HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certily that 1 have read this application and state that Orn above VENTILATION FAN (SINGLE) 3.00
ofornsotion is Correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction,and BOILER-COMP(3H.P.or 100,000B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) ugreo to Save, indemnify 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 3.00
granting of this permit. MECH.CONT. LIC�NO. MECH.
U e�� TOTAL TOTAL �
r Signatte ol'Applicunl/Contractor -Date V'
IOFFICE COPY