8852 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT 1 DENTI FIC PERMIT NUMBER
.1UILDING jay APPLICATION & PE T O C
5 o a�
Q BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'$ PLAN CHECK VALIDATION
ME
QTV. ELECTRIC PERMIT FEE
R IfPROrvE
CONTRACTOR'S UTLETS-SWITCHES-RECEP 10.00/1.00
[.r uc.No. LIGHTING FIXTURES 10.00/1.00 a(
CONTRACTOR PPLIANCES-RESIDENTIAL 4.00
A OR $ „ 'x
e, PRONE"18g� 13 2 PANELS 10.00 Q - DATE OF APPLICATION
OORCHITEC a11t DTCIst1 - PANELS (OVER 200 AW 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER � k f 1.
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ADDRESS ENG SPECIAL CIRCUIT 5.0D S PERMIT VALIDATION
IIP EMP. METER OR POLE INS. 20.00 l l
APPLICANTS MOTORS
ADDRESS SEE FEE SCH.
SERVICE CHANGE 20.00
w
00 LICENSED CONTRACTORS DECLARATION TEMP.POLE ^ 30.00
affront
l
rt U u I hereby afl that I am licensed under provisions of Chapter 9 ORG ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and
¢ m - BLDG. ELECT. PLG. MECH,
r m z Professors Co ,u dwny license is in full fo n
z o w - License CI s YY Lie.Numbern"n of CUpe�IOO 0
m r w Dale Convector
City
a x BUILDING PERMIT
¢ ¢ ¢ OWNER-BUILDER DIiCLARATION
p d v INFORMATION
w ; m I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
H a_ U.
Law for the following reason, 7031.5.Businessand Professions PERMIT ISSUANCE - VALUATION S/FT.
Cade:An 10.00 Q
Any city or county which requires a permit to construct,alter,
as ¢ a o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
O LL requires the applicant Cor such permit to file a signed statement that TOTALS
u w m lie is licensed pursuant to the provisions of the Contractor's License PERMIT TO
HiQ
Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe
4 O Business and Professions Code)or that he is exempt therefrom and QTV. PLUMBING PERMIT FEE
¢ H pm the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
d ; _ by any applicant for a permit subjects the applicant o a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred doll an(5500).):
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 4.00 OCG GROUP RES.UNITS
their sole 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
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP - 5.00 SG.FT.FLOOF AREA TOTAL ACREAGE
• himself or through his own employees.provided that such improve-
tents are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.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 hu did not build or im- RES IND CON PB Omer
Prove forpurposc of sale.l. - INDUSTRIAL WASTE INTER. 30.00
❑ 1,as owner of the property,am exclusively contracting with 1:1 El
licensed.contractors to construct the project(Sec. 7044,BusinessLAWN 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 SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to SEWER-SAN V-STORM EA.200ft/70.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. - 5.00
1 hereby infirm that I have a certificate of consent to self-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE N0.
copy there 00,Lab C.) /' q
Poliey No O mpany� -1L,
O ❑ Certified copy is hereby fust 1 d. RE$PRINK ENERGY T Y4
z Z Certified cop is filed uh,(Phe it inspection d�vision.
O Applicant n w// �jy7�,��f a. / MISC.- REFER TO ORD. Y E] NE] v ❑ IN
F fin PERMIT ISSUANCE 70.00
-LU CE Tl19CATliPOj�ENSATION ION PROMWORKISRS' FLDOD ZONE A.LU.C.
W � COMPENSATION INSURANCE a PW.CONTR. LIC.No. PLG.
CL Z( This section need not be completed if the permit is for one TOTAL Y El NE] Y E] N[:]
hundred dollars 1$100)or less)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
W F mit is issued,I shall nut employ any person in any mariner so as to
OW become subject to the Workers Compensation Laws of California: BUILDING
a Date Applicant ALTER OR ADD TO MECH. 5.00
} m NOTICE TO APPLICANT: If,after making this Certificate of
F ? emption,you should become subject to the WorkersCompensation 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 10=CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,OODC.EM.) 6.00 SEISMIC FEE '
I hereby affirm that mere is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sea MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATI NG UNIT 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that l have read this application and state that tri above VENTILATION PAN (SINGLE) 4.00
• - information is correct.I agree to comply with all city and county PLUMBING
ordinances and slate laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep hariiless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs an expenses which CONST.TAX
may in any way accrue ag inst said City m co sequence of the PERMIT ISSUANCE 10.00
notiThs ermit MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL.
jS,�g1"ug,,J"Apphcar1/Co tractor ate
OFFICE COPY