C8559 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENT[FI CATION PERM NUMBER
BUILDING APPLICATION & PERMIT
AooREss
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL I
R' PL CHECK VALIDATION
NAME OTY, ELECTRIC PERMIT FEE
HONE \ -
NAmeAcoas UTLETS-SWITCHES-RECEP 10.00/1.00
_IC No. LIGHTING FIXTURES .10.00/1.00 S'
AADDRESS ro it - PPLIANCES-RESIDENTIAL 4.00
NTRAC
PHONE PANELS 10.00 DATE OF APPLICATION
OR
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER
uc.No. SIGNS TRANS. 3.00
ADD Ess eec. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
'to TEMP.METER OR POLE INS. 20.00
ADDRESS MOTORS SEE FEE SCH. S
ADDRESS
SERVICE CHANGE 20.00
o o LICENSED CON IRACTORS DECLARATION TEMP.POLE 30.00
a is u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w (commencing with Section 7000)of Division 3 of the Business amt
¢ y BLDG. ELECT. G. MECH.
" y z Professions Code,and my license is in full force and effect ❑_ ❑` ❑ ❑
zo i w o License ClassLic.Number
" al Date Contractor
a m E * BUILDING PERMIT
le rc ¢ OWNER-BUILDER DECLARATION
o w u et INFORMATION
E
3S N I hereby affirm that I um exempt from the Contractors License MIS C.- _ REFER TO ORD „
u_ a- Law for the following reason. 7031.5.Business and Professions PERMIT ISSUANCE 1flA0 _ VALUATION S/FT.
to f Code:Any city or county which requimsa permit toconstomn,alter.
pr p' y of to its issuance,also ELEC.CONTR. LIC.NO. S �0
¢ Ix ¢ 0 hoprove,demolish,or repair an structure,prior ELEC.
LL requites the applicant for such permit to file a signed statement that TOTAL / l PERMIT TO
A w m he is licensed pursuant t0 0m provisions of the Contractor's License
" zi Law(Chapter 9(comntencing with Section 7000)ofl)ivision 3 of the
¢ Business and Professions Code)or that he is exunpa therefrom;cul GTY. PLUMBING PERMIT FEE
f i o
KHp the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant loa civil penalty
of not more than five hu'ndmel dollars,($500),1-- ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.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 Commctor's 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 st so.FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees,provide)that such imprave-
mentsarenotintendedoroffcreoyeesarovided that such
building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, - . -the owner- GAS EASYSTEM OV ER'4 (EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for Purpose of sale.). INDUSTRIAL WASTE INTER. 3000 RES IND CON PB Omer
❑ 1,as owner of the property,am exclusively contracting with . ❑ ❑ ❑ ❑ ❑
Iicense0 contractors to construct the project.Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Pro1'ewions Code: The Contractor's License Law does not apply I
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 contractotfs)licensed pursuant to SEWER-SANITARY-STORM EA.200f1/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
rea❑onl v Ixempt under Sec. .BAP.C.for this WATER HEATER W/VENT 6.00
Owner __ Date 'e ' WATER SYSTEM 5.00 Ace.DnrE ACC.FILE NO.
WORKERS'COMPENSI ION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certiflcatc of Workers'Compensation Insurance.or a certificJ
copy thereof(Sec.3800,Lxb.C.).
Policy No. Company
Q ❑ Certified copy is hereby famished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is tiled with the city inspection division. MISC- REFER TO ORD.O Applicant Y ❑. N❑ Y ❑ IN[J
~'N PERMIT ISSUANCE 10.00
LLI CIiRTI PICCOMPEN AI ION INSURANCE
ROM K'OR KIi RS' FLOOD ZONE A.L.U.C.
W need not
ifthe PLG.CONTR. LIC.NO, PLG. Y❑ N❑ Y❑ IN E]
,Q. O (This section nee) not be completed if the permit is for one TOTAL
D'Z hundred dollars IS 100)or less.)
U _O 1 certify that in the perlormmnce of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
W I- mit is issued,1 slutll not employ any person in any manner so as to
U becmne subjectCalifornia.
to the Wmkcrs'Compcnsation Laws of C
U i Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} 0 NOTICE TO APPLICANT': IL after making this Certificate of 1>x-
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 �.3
U FEE
such provisions or this Permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000GF.M.) 6.00 SEISMIC FEE d�
1 hereby affirm that there is a construction lending agency]or EXHAUST HOOD (WITH DUCT) 5.00
the pOl'o mance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). I H EATING UN IT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lenders Address HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that l first,readIli%application and state that the ubovc VENTILATIONFAN (SINGLE) 4.00
information is cor,cct. I agree to comply with all city and county PLUMBING
ordinances and state laws miming to building construction, anti BOILER-COMP(3H.P.ur100,000B.T.U.) 6.00 `
hereby amhorize representatives of this city m 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 'n any way accrue agar t Said City in conuquence of the PERMIT ISSUANCE 10.00
gr ti gnl'thin mil. MECH.CONT. •LI0.N0. MECH. r+..
TOTAL TOTAL ,F/��` j
Sign Wre of ApPh /Con a Dae (J /
/(_ V INSPECTOR COPY--