8600 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT lDENT]FICATION PERMIT NUMBER AAPPLICATION & PERMIT
G o
ADDRESS
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
E
NA
E s OUTLETS-SWITCHES-RECEP 10.0011.00
uc.NO. LIGHTING FIXTURES 10.00/1.00 --
Aiofla
ADDRESS PPLIANCES-RESIDENTIAL 4.00
CONTRACTOR
___PHONE PANELS . 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.rv0. SIGNS TRANS. 3.00
ARCHHE OR ENG. SPECIALCIRCUIT 5,00 PERMIT VALI DATION
'
ZIP EMP.METER OR POLE INS. 20.00
Ars
ADDDRESSDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 .,
o O o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a L,v I hereby affirm that I am licensed ..it,,provisions of Chapter 9 ISSUANCE DATE
a "' (commencing with Section 7000)of Division 3 of the business and
a w BLDG. ELECT. PLG. MECH.
F m z Professions Code,and my license is in full force and effect. ❑ ❑ ❑ ❑
o i m o License Class Lie.Number
Date Contractor
¢ x re BUILDING PERMIT
¢ ¢ re DECLARATION INFORMATION
K
;u H I hereby affirm that I am exempt from the Contractory Lieunse MISC.- REFER TO ORD VALUATION
F o¢o¢ Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 $/FT.
Code:Any city or counly which requires a permit to construct,alter,
IS ¢ a o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
D, requires the applicant far such permit to file a signed Statement that TOTAL �' PERMIT TO
w m ac m he is licensed pursuant to the provisions of the Contractor's License
A
F Z Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe G
S i D Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE Ee-E
¢ o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
dam by any applicant for a Permit subjects the applicant ton civil penalty ALTER-DRAIN -WATER IEA.) $.00
of not more than five hundred dollars($500)J'
❑ L as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sale compensation,will do the work,and the structure IS not _
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 _
Code:The Contractors License Law does not apply to an owner of
properly who builds Ur improves thereon,and Wh)does Such work FIXTURES-PER TRAP 5.00 SQ FT,FLOOR AREA TOTAL ACREAGE
himself or through his own ant plOyres,provided that well impiovo-
ments are not intended or offered for sale.IL however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or inr
P
rove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Diner
❑ I,as owner of the properly,am exclusively comracling with ❑ E3 C] E) E]
licensed contractors to construct the project ISec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 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 SPO INKLERS-OV ER 5(EA.) 1.00
contracts for such projects with a contractorl s)licensed pursuant to SEWER-SANITARY-STORM EA.2001t/10.00
Om Contractors License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B. P.C.for this WATER HEATER W/VENT 6.00
rasa
er ale WATER SYSTEM 5.00 ACC.DATE ACC.PILE NO.
w KERS' ' :NSA Cx,-DEc RATION WATER TREATING EQUIP. 5.00
I y affirm that I have a certificate o consent to self-insure, ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No. - Company
O ❑ Certified ropy is hereby furnished. ` FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is riled with the city inspection division. MISC.- REFER TO OR D.
Q Apphe...I - Y ❑ N❑ V ❑ N❑
Cc: N CERTIFICATE OE EXEMP'❑ON FROM WORKERSPERMIT ISSUANCE ' 10.00 FLOOD ZONE A.L.U.C.
Lu COMPFNSAI'ION INSURANCE PLG.CONTR.", LIC.NO. PLG,
(L O ('('his section need not he Completed if the permit is I., one TOTAL Y❑ N❑ Y ❑ N❑
D 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 F mit is issued,I Shall not employ any person in any manner so as to
U become subject to the R'orkers'Compensation Laws of California.
U a Dale-Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} 0 NOl'ICE'rO APPLICANT: IL after making this Certificate of Ex-
F Z emption,you should become subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this Permit shall be deemed revoked. AIR HANDLING UNIT(TO 10OW C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is it construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the perti rnlance of the work for which this permit is Issued(Sec. MICROFILM
3097,Civ.C.), HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.0.50 ELECTRIC /� o-G
-
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4,00
• information is correct.I.agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, mid BOILER-I,X)MP(3 H.P.Dr 100,000 B.T.U.) 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,judgnwnts, costs and cxpetrtes'which PERMIT ISSUANCE 10.00 CONST,TAX
may
By way accrue au' st said City in Consequence of ilia
tin rf this permit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
ana ant tetra - D e
INSPECTOR COPY
i