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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION &PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
9076
BUILDING
AD D ESS
7�%a N�'� ,
O N R'S
NAM
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ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
DATE OF APPLICATION
CONTRACTOR'S
NAME
LIC. NO.
OUTLETS - SWITCHES - RECEP 10.00/1.00 ja -
LIGHTING FIXTURES 10.00/1.00 lo
CONTRACTOR'S
ADDRESS
PHONE
APPLIANCES - RESIDENTIAL 4.00
PANELS 10.00
ARCHITECT
OR
ENGINEER
LIC NO.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE
P.C. NO.
SIGNS TRANS. 3.00
ARCH . OR ADDRESS ENG.
zIP
SPECIAL CIRCUIT 5,00
PERMIT VALIDATION
�/ X'
ISS ANCE DATE
EMP. METER OR POLE INS. 20.00
APPLICANT'S
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
License Class Lic. Number
Date Contractor
OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5, Business and Professions
Code: Any city or county which requires a permit to construct, alter,
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars ($500).):
❑ 1, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
ments are not intended or offered for sale. If, however, the building
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or im-
prove for purpose of sale.).
❑ I, as owner of the property, am exclusively contracting with
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply
to an owner of property who builds or improves thereon, and who
contracts for such projects with a contractor(s) licensed pursuant to
the Contractor's License Law.
❑ I am exempt ider S B.&P.C. fo this
reason
TEMP. POLE / 30.00
BLDG.
❑
ELECT.
PLG.
El
MECH.
,
"� t
BUILDING PERMIT
INFORMATION
MISC. - `
PERMIT ISSUANCE 10.00
VALUATION
$/FT.
ELEC. CONTR. LIC. NO.
ELEC. 7
TOTAL e10 --
PERMIT TO
_
QTY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
ALTER -DRAIN &VENT -WATER (EA.) 5.00
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
FIXTURES - PER TRAP 5.00
SO. FT. FLOOR AREA
TOTALACREAGE
GAS - EA. SYSTEM - 1 I NC.4 OUTLETS 6.00
GAS EA. SYSTEM -OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON PB Other
❑
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
ASSESSORS PARCEL NO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 6.00
Owner Date
WORKERS' OMPENSATION DECLARATION
l hereby affirm that 1 have a certificate of consent to self -insure,
or a certificate of Workers' Compensation Insurance, or a certified
copy thereof (Sec. 3800, Lab.C.).
Policy No. Company
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the city inspection division.
Applicant
n WATER SYSTEM 5.00
L
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
ZONING
ENG. SITE NO.
FIRE SPRINK
Y❑ NEI
ENERGY T-24
Y E] NEI
MISC. REFER TO ORD.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
hundred dollars ($100) or less.)
1 certify that in the performance of the work for which this per-
mit is issued, 1 shall not employ any person in any manner so as to
become subject to the Workers' Compensation Laws of California.
Date Applicant
PERMIT ISSUANCE 10.00
FLOOD ZONE
Y ❑ NE]
A. L. U. C.
Y [:] N
PLG. CONTR. LIC. NO.
PLG.
TOTAL
OTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
emption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec.
3097, Civ.C.).
APPLIANCE 5.00
PLAN CHECK
FEE
AIR HANDLING UNIT (TO 10=C.F.M.) 4.00
AIR HANDLING UNIT (OVER 10)[00C.F.M.) 6.00
SEISMIC FEE
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address
1 certify that I have read this application and state that the above
information is correct. 1 agree to comply with all city and county
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments costs and expenses which
may in any way accrue City in consequence of the
granti rs pe
HEATING UNIT (OVER 100,000 B.T.U.)9.50`
ELECTRIC
'36
VENTILATION FAN (SINGLE) 4.00
PLUMBING
BOILER- COMP (3 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
MISC. - REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 10.00
MECH. CONT. LIC. NO.
MECH.
TOTAL
TOTAL
Signature of A rcant/Contractor Date
OFFICE COPY