8758APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LID I NG PROJECT I DENT[ FICATI ON
APPLICATION &PERMIT
BUILDING - ELECTRICAL -PLUMBING - MECHANICAL
PERMIT NUMBER
S
r
I �U
ADORESS
ADORE SS
SJ
OWNER'S
NAME
QTY- ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
,
C
u DATE OF APPLICATION
Name ACTORS
v LIC. No,
UTLETS-SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
ADDRESS TORS
PHONE
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
OARCHITECT
ENGINEER
' LIC. No.
PANELS (OVER 200 AMP) 20,00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARC" OR ENc.
ZIP
SPECIALCIRCUIT 5.00
PERMIT vnu DATION
/
ISSUANCE DATE
BLDG. ELECT. PLG. MECH.
❑ ❑ ❑
EMP. METER OR POLE INS. 20.00APPLICANTS
ADDRESS
-
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9
(commencing with SectioR 7000) of Division 3 of the Busincov and
Prolessions Code. and my license is in full forte and effect.
License Class Lic. Number
Date Contractor
OWNER -BUILDER DECLARATION
I herebyMISC.-
collo that I am exempt from the Contractor's License
Professions
Code: Any cityl orcountng reason. (S requires a permit to construct,
Code: Any city or county which requirese permit tocoasuanc . also
improve, demolish, Or repair any strPutrid
peer to its issuance. that
requires the applicant for such permit to file a signed statement that
1. Fill
t he
he Islicensed(Chapter 9 (comlL en the with Secti n the f) ofDiCter F 3 of
of Division 3 of the
Law (Chapter 9 (commencing with Section is exempt
Business and Professions x edp) or that he is exempt therefrom and
the basis for the alleged exemption. Any applicant
of Section 7 nsity
subjects 5500).licmtlloacivil Penally
by any applicant fore hundred
of not more than five Imndred dollars ($500).):
❑ h as owner of the property, or my employeeswish wages as
their sole compersalton, will do the work, and the stnmtum is nut
intended or offered for sale (Sec. 7044, Business and Professions
Code: Tile 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
Twins ot s are nintended 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,
ITo I purpose of sole.).
I, as owner of the property, am exclusively contracting with
Business
li ed contractors: construct the project (Sec. does
a d n owner of Code: The Contractor's Iimproe law docs nm apply
y who builds or Improves used p, and who
to contracts
owner of h projects
the Conls for such projects with a conlrador(s) licensed pursuant to
the Comradm's License Law.
❑ I amexvmptundcr Sec. ,B.&P.C. for fills
reasoll
TEMP. POLE 30.00
BUI DI NG PERMIT
I FORMATION
REFER TO ORD
PERMIT ISSUANCE
VALUATION
$/FT.
ELEC. CONTR. LIC. NO.
ELEC.
C.
TOTAL /
ERMIT TO
CITY PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
ALTER -DRAIN -WATER IEA.) 5.00
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
FIXTURES - PER TRAP 5.00
GAS-EA.SV$TEM-11NC.40UTLET$ 6.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDING USE
RES IND CON PB 011ier
❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER, 30.00
LAWN SPRINKLERS -1 INC5 V.B. 6.00
ASSESSORS PARCEL NO.
LAWN SPRINKLERS -OVER 5 IEA.) 1.00
SEWER -SANITARY -STORM EA. 200ft110.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 6.00
w - Dam
WATER SYSTEM 5.00
WORKERS'COMP1iN5nTION DECLARATION
1 hereby affirm that I have a certificate of consent to setf-insure.
0r a certificate of Workers' Compensation Insurance, or a certified
copy thereof ( Sec. 3800, Lab.CJ.
Policy No. Company
ACC. DATE
ACG FILE NO,
WATER TREATING EQUIP. 5.00
ZONING
ENG. SITE NO.
Cl Certified Copy is hereby furnished.
❑ Certified copy is file) with the city inspection division.
Applicant
MISC.- REFER TO ORD.
FIRE SPRINK
V N
❑ ❑
ENERGY T-14
Y N
O ❑
CERT1171CATI>01: EXEMPTION FROM WORKERS'
CO.1IPENSATION INSURANCE
('Phis section need riot be cetnpletCd if the permit is for one
hundred dollars IS 100, or Icss.l
I certify that in the performance of the work for which this per.
.it i issued, I shall not employ any person in any manner so as to
become subject to the Workers' Compensation Laws of California.
Date Applicant
PERMIT ISSUANCE 10.001
FLOODZONE
Y ❑ N ❑
A.L.U.C.
Y ❑ N ❑
PLG. CONTR. LIC. NO.
PLG.
TOTAL
CITY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
,
ALTER OR ADD TO MECH. 5.00
NOTICE: TO APPLICANT: IL after making this Cerllfkete 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
I hereby affirm that (here is a Construction lending agency for
the performance of the work for which this permit is issued (Sec
3097, Civ.C.).
Lender's NamAddy
Lender's Address
I 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 slate laws relating to building construction, and
This city to enter upon the
hereby au0mrire representatives forms inspection
hereb coauthored property forinsp ofth i puituhsus,
(We) ogre,, to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue against said City in Consequence of the
gianling Of thin per lot,
/C
3 ✓ti
APPLIANCE 5.00
AIR HANDLING UNIT (TO 10MC.F.M.) 4.00
PLAN CHECK
FEE
AIR HANDLING UNIT(OVER 10DWC.EM.) 6.00
SEISMIC FEE
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
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.
PERMIT ISSUANCE 10.00
CONST. TAX
MECH. CONT. LIC. NO.
MECH.
TOTAL
TOTAL
nature of Applicant/Com a9r Dine
INSPECTOR COPY