8519 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
ILILDING ^� APPLICATION & PERMIT
T ADORES LoA 41.i CISl L.CIILJCI PIQCI BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 8519
OWNER'S - PLAN CHECK VALIDATION
NAME CITY. ELECTRIC PERMIT FEE
•i
l PHONE
QNTRACTOR'S rvAMEOUTLETS-SWITCHES-RECEP 10.0011.00
'T LIC.No. LIGHTING FIXTURES 10.00/1.00
C PPLIANCES-RESIDENTIAL 4.00
Y ADDRESS C
\/`,! PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT— PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
1 ENGINEER -
uc.No. SIGNS TRANS. 3.00
moo Ess ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP / EMP.METE6 OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH. ¢'
ADDRESS
. i SERVICE CHANGE 20.00
•
-00
0o LICENSED CONERACTORS DECLARATION ITEMP.POLE 30.00
a u u 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business ant] BLDG. ELECT. PLG. MECH.
�, i Professions Cod anJ my license is in full force and effect.
zo w -, License Class Lie.Number. • -I ❑ ❑ E]0 H w Date- Ell, - ContractordE6c6/' x,
a m BUILDING PERMIT
¢ ¢ ¢ OWNER-BUILDER DECLARATION
¢ w o INFORMATION
W ;LL N I hereby affirm that I am exempt from the Contractor's License MISC.- « REFER TO ORD { VALUATION 5/FT.
F lvoa Law for the following reason,(Sec.7031,5,Business and Professions PERMIT ISSUANCE 10.00 _ -
Code'.Any city nr county which requires sperm It m cc.n.trust,aIle,
EC ¢ a p•' improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
D m requires the applicant for such permit to file a signed statement that TOTAL ot/ PERMIT TO
E:
m he is licensed pursuant to the provisions of the Contractor's License
Law(Chapter 9(cmumenciagwith Section 7000)of Division 3 of to Ta'/-//0 000LC-
a Business and Pmfeseions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
ou by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
O 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEV ICE 4.00 OCC.GROUP RES.urvrt5
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Pro(essiuns DRAINS-FLOOR,ROOF,AREA,COND. 5.00 -
Codc'I'he Contmclo-'s Limnse Law docs not apply to an owner of '
property who builds or improves fiction,and who docs such work FIXTURES-PER TRAP 5.00 SO.rT.FLOOR AREA TOTAL ACREAGE
• himself'or through his own employees.provided that such improve.
cents are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 1 NC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or inn.
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Othe,
❑ I,as owner of the property,am exclusively'contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- I INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:'Tire Contractor's License Law docs 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 contractods)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ l am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00 '
came
Owner Date WATER SYSTEM 5.00 ACG DATE ACC.FILE NO,
WORKERS'COMPENSA'IION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to sell insurc. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. C......air, �- r
❑ Cetlified copy is hereby fuLhld. FIRE SPRINK, ENERGY T 24
z Z Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
0 APPlicmt Y❑ No v ❑ N❑
CC r2 CERTIFICATE OI'EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.c.
LL > COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG. Y❑ N❑ Y ❑ NO
CL 0 (1 his section need not be completed if the permit is for one TOTAL
:) Z hundred victims IS 100)or less.)
U 0 I certify that in the performance of the work for whichthis per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued.I shall not employ any person in any manner m as to
0 become subject to the Workers'Compensation Laws of California.
i Date APPlicantALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICI7 TO APPLICANT: If,after making this Certificate of fix
Z_ emption,you should become subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith congrly with FEE
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,10WC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the Ix7.C'orCance of tire MICROFILM
e work far which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC --
I certify that I have read this application mul,tate that theabove VENTILATION FAN (SINGLE) 4.00 -
information is estate. I agree tcomply with all city and county PLUMBING
ordinances and stale laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.1 6.00
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) agree 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 tri PERMIT ISSUANCE 10.00
granting of this pem.it. MECH.CONT. LIC.NO. MECH.
7 U TOTAL TOTAL
rnjillature Appli<anl/ ontractor Date-
INSPECTOR COPY