8571 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT ����
ADO E55
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
/ PHONE
NAAMERAc Rs OUTLETS-SWITCHES-RECEP 10.00/1.00
r sec.Na. LIGHTING FIXTURES 10.00/1.00
'D
ADDRESS a APPLIANCES-RESIDENTIAL 4.00
•
PHONE PANELS 10.00 DATE OF APPLICATION
7WITT - PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO,
OR
ENGINEER
LIC.NO SIGNS TRANS. 3.00
ARC H.OR ENG. PERMIT VALIDATION
ADDRESS SPECIALCIRCUIT 5.00
ZIP TEMP.METER OR POLE INS. 20.00 n
ADDRESsTa MOTORS SEE FEE SCH. / -� r••
+- SERVICE CHANGE 20.00 ��-��-•��-
ct
'02 LICENSED CON'TRACTORS DECLARATION TEMP,POLE 30.00
u sl hereby affirm that I ore licensed under provisions of Chapter 9 ISSUANCE DATE
H G w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F H z Professions Code,and my license is in full cc an effect.
z O m - License Class_Lic-Num r ❑ ❑ 1-1
g z r reo Date Come cto
a m s BUILDING PERMIT
BE ¢ w Q OWNERBUILDERDECLARATION INFORMATION
w3 u m 1 hereby affirm that 1 am exempt from the Contractors License MISC.- REFER TO ORD
LL o a Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
tywCode:Any city orcounty which requires a permit to construct,alter,
Q2 a o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
- O ¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
E
m I he is licensed pursuant to the provisions of the Contractor's License
r z s- Low(Chapter 9(commeneingwiOt Section 7000)of Division 3 ofthe An��/
e Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE /_/ r7
re F p the basis for the alleged exemption.Any violation o(Section 7031.5 STORIES TYPE CONSTR.
aim by any applicant for a permit subjects the applicant to a Civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(S500.):
❑ 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 sl ruclure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor'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 SO.FT FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,howcve r.the building GAS-EA.SVSTEM-11NC.40UTLETS'6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 (EA.) 200
builder will have the burden of proving that he did not build or ire - . - . .
- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
❑ I,as owner of the properq.'am exclusively contracting with El ❑ E3 ❑ 0
licensed contractors to construct lhe.project(Sec.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 SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contraclor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
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
I hereby affirm that I have a certificate of consent to elf-insure. ZONING ENG.SITE NO.
or a certificate of workers'Compensation Insurance,or a certified
copy thereof(Sec 3800,Lab,C-).
Policy No�'ompar y 1x7'�P _'_'Iz�
0 ❑ Cer tied py is hereby'fum xn FIRE SPRINK ENERGY T-24
z Z Ge-ccrlified copy is Bled with the City inspection division.
O Applicant FIµSf❑ bft:E Zyr[:P� MISC.- REFER TO ORD. YE] NE] v ❑ N[:]
~ w PERMIT ISSUANCE 10.00 - PLOOOZONE A.L.U.C.
UJ - ♦CERTIFICCOM E EXEMPTION ION PROM WORKERS'
W COM not be coo INSURANCE PLG.cONTR. LIC.NO. PLG. Y El N� Y C] NE]
d O (This section need not be completed if the permit is for one TOTAL
� Z hundred dollars(5100)or less.)
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in any manner So as to
0 w become subject to Ore workers'Compensation Laws of California. BUILDING
2 Dale Applicant ALTER OR ADD TO MECH. 5.00
} ED NOTICE TO APPLICANT: If,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.p`it shall be deemed cooked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Cio.CJ, HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name H EATI N G UN IT(O V ER 100,000 B.T.U.)9.50
Lender's AddressIf ELECTRIC
I certify that l have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
• information n estate la agree to comply with all city and county PLUMBING
I houraces and state laws relating to building construction, and ty BOILEA-COMP(3 H.P.or 100,0008.T.U.) 6.00
hereby authorize representatives of this city m enter upon the BOILER-COMP (Over 100.000 BTU)SEE FEE SCM. MECHANICAL v
a bove mentioned property for inspection purposes. L
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
0 granting of this per MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Sign o- ican/Contrar Dale A{
INSPECTOR COPY