5800 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT PERMIT NUMBER
BUILDING
ADDRESS
U G BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 5800
A.ti�s - PLAN CHECK VALIDATION
NAME - OTY. ELECTRIC PERMIT FEE
x& / PNONE
NAME
RAcrOR$ O UTLETS-SWITCHES-RECEP 5.00/1.00
7 sic.No.3S LIGHTING FIXTURES 5.00/1.00
r-ONrRAc oR' - PPLIANCES-RESIDENTIAL 4.00
aooREss
O PNONE -/Q
f1O PANELS ' 5.00 DATE OF APPLICATION
0.RCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO,
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRESSSR exa - SPECIALCIRCUIT '5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
APPLICANT MOTORS SEE FEE SCH. r�/
ADDRESS
SERVICE CHANGE 10.00 ap/ED�y
'''nun
w o o LICENSED CONTRACTORS DECLARATION
<i u I hereby affirm(het I am licensed under provisions or Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of(he Business and
¢ u BLDG. ELECT. PLG. MECH.
r w m Professions Code,and my license is in full fo emend c ❑ ❑ � ❑
Licen 1 Lic.Numbcr.7.f
0 fl F 0 Date.�O / Contractor /jC-�e �/yv.l ( /t C/t °P
a Y E /' , - BUILDING PERMIT
A.0 w
OWNER-BUILDER DECLARATION INFORMATION
A.
;u r 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
FLLN¢ Law for the following reason.(Sec.1031.5,Business and Professions PERMIT ISSUANCE 6.00 YALUaTlO�
Code:Any city or county whichrequiresu permit to construct,alter,
� �^g / L
2 a ¢Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
O LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
n w
As be is licensed pursuant to the provisions of the Contractor's License
r z i
Law(Chapter 9(commencing with Section 7000)of Division 3 of the C,'30 Ra-T
¢ Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
re o the basis for the alleged exemption.Any violation of5ection 7031.5 5 TYPE CONSTR.
in by any applicant for a permit subjects the applicant toacivil penalty ALTER-DRAIN&VENT-WATER IEA.l 4.00 �
of not mare than fivehundred dollars(5500).): cr
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00
their sole compensation,will Jo the work,and the structure is not B UP RES.UNITS
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4,00 ' 4 O pU
Code:The Contractor's License Law does not apply to an owner of L
properly who builds or improves thereon,and who doessuch work FIXTURES,PER TRAP 4,00 SD.FT.FLOORAREA TOTALACREAGE
• himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the budding GAS-EA.SVSTEM-I1NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 4000 RES IND CON PB Other
i. C] 1,as owner of the property,am exclusively contracting with 1:1 El El ❑ Cl
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 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 contractors)licensed pursuant to
the Contractor's License Law. • SEWER-SANITARY.STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I an,txempt ander Sec.-,BAP.0 for illi WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I herchy affirm that I have a certificate of consent to selNnsure.
ora certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished. - FIRESPRINK ENERGY T 24
'Z_ Z ❑ Certil'icd_cony '< fi.d w'Ih thy: yty'inspe<tion division. MISC- REFER TO ORD.
plicant �YY/ .r^7yfl Y E] N Y C] NE]
F w PERMIT ISSUANCE 6.00
LU - CER'I'IFICA'I'Ii OF EXEMPTION FROM WORKERS' - FLOOD ZONE A.L.U.C.
W �_ COMPENSATION INSURANCE - PLG.CONTR. LIC.NO. PLG,
CL 0 (This section need not he Completed if the permit is for 11-C TOTAL Y E] N[3 Y [:] No
0 Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- OTY, MECHANICAL PERMIT FEE FEE SUMMARY
LL I. mil is issued,1 shall not employ any person in any rune,so us to
O become subject to the Workers'Compensation Laws of California.
y Date ApplicantALTER OR ADD TO MECH. 4.00 BUILDING 4,�" ,,(U
>_ N NOTICI7 TO APPLICANT: If,after making this Certificate of 17x-
F. Z ennption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions Ell the Labor Code, you most lorthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=11F,IYL) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=1 .F.M.) 5.00 SEISMIC FEE aTJ
I hereby uflinm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the wor for which this permit is issued(Sec. - MICROFILM
3097,Civ.C.L / C HEATING UNIT(TO 100,000 B.T.U.) 4.00
Leader's Name .
HEATING UNIT(OVER 100,000 BT.U.)7.50
' lender's Address-d.Q. v( .�?�YZ ELECTRIC
I certlly•that I have read lhlsapPhCBtlon' dd sate that lie.l(ieabove VENTILATION FAN (SINGLE) 3.00
information is correct. I agree.to comply with all city and county PLUMBING
ordinances and stale laws relating to building construction, and BOILER-COMPI3 H.P.or 700,000 B.LU.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentinned property 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 which PERMIT ISSUANCE 3.00 CONST.TAX
May is any way accrue against Said City ' consequence of the
grant* of this pe mit / MECH.CONT. LIC.NO. MECH.
TOTAL TOTALS
Si Iature of Ap icant/Co ractor D' c
OFFICE COPY