10187 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON PERMITNUMBER
BUILDING APPLICATION & PERMIT O �.�
AOORE55
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
_)
roNAME OTY. ELECTRIC PERMIT FEE
PHONE � L
mama AcroRs - OUTLETS-SWITCHES-RECEP 10.00/1.00
V Lic.No. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S
• ADOREss �V" APPLIANCES-RESIDENTIAL 4.00
Q �PNONE PANELS 10.00 DATE OF APPLICATION
OARCHITECTPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC,No. SIGNS TRANS. 3.00
ARCII.On
ADDRESS ENG. SPECIALCIRCUIT 5.00 DECERMIT VALIDATION
za, EMP.METER OR POLE INS. 20.00 U 2 G 1985
ADDRESS
APPLICANT S MOTORS SEE FEE SCH.
ADDRESS -
SERVICE CHANGE 20,00 City of Cupertino
'02
wo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a o u 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y < w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r Z Professions Cod and license is in full for p (ff t ❑ ❑ ❑
z o - Licen ass - Lic.NumbeS�`SCJCtl
9 w Date Contractor �y�`S�ilL[�;1(i'�cyL
¢ a w a OWNER-BUILDER DECLARATIbtT - \ BUILDING PERMIT
- o A INFORMATION
N i. y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
F u O J Law for the following reason.(Sec.7031.5,Busumasand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
a 0 Code:Any city or county which mquiress permit to construct,eller,
2 2 xf FO improve,demolish,Or repair any structure,prior m its issuance,also ELEC.CONTR. LIC.NO. ELEC.
n G ¢ requires the applicant for such permit to file S signed Statement that � TOTAL P IT TO
E
$m he is licensed pursuant to the provisions of the Contractor's License
ri > Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
i o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ H the basis for the alleged exemption.Any violation of Section 7031.$ STO"IES T PE CONSTR.
by any applicant for a permit subjects the applicant as civil penally gLTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP REB.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 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
menta are otint ode ownemployees,for le,If,however the
improve- GAS-EA.SVSTEM-1 6.00
` L mems are not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner-
builder
wner GqS-EA.SYSTEM•OVER 4(EA.) 2.00 'BUILDING USE
builder will have the burden of proving that he did not build or im- IND CON PB Guns,th
prove for purpose of e.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with
licensed contractors to construct the 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 contractors)licensed pursuant l0 BEWER-SAN V-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ l am exempt under Sec ,B.AP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Dale WATER SYSTEM 5.00 ACC.DATE ACL.FILE NO.
WORKERS'COMPENSATION DECLARATION WATERTREATIN EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Coi pensatmn Insurance,0 " cert ificd ZONING ENG.SITE NO.
copy thereof(S��as.�ddB8BB 7.
Policy No._�Company O(g.14
0 ❑ Certified co"hereby furnished.
Z Z �' Cersifi d is file i 11 the city iQipectiop plvlNon. FIRE SPRINK ENERGY T�ZA
O Applicant yt C(.�,af. />� MISC.- REFER TO ORD. vE] N❑ v � NC]
= �+ PERMIT ISSUANCE 10.00
LU CIiRTIFICCOMONSATIOTINS PROM WORKERS' FLOOD ZONE A.L.0.C.
W � COMPENSATION INSURANCE � P G.CONT L C.NO PLG.
Q. Z (This section need not be completed if the permit is for one TOTAL V 0 N� V ❑ NL]
hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- OTV MECHANICAL PERMIT FEE FEE SUMMARY
U. H mit is issued,I Shall not employ any person in any manner So as to
0 W become subject to the Workers'Compensation Laws of California.
y Dale Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F z emplion,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 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0J=QRM.) 6.00 SEISMIC FEE
I 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,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name H EATING U N IT(OV ER 100,000 B.T.U.)9.60
Lender's Address ELECTRIC
I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
I�1 ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6:00
J hereby authorize representatives of Ibis city to enter upon the BOILER-COMP Over 11X1,000 BTUI SEE FEE SCM. 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 PERMIT ISSUANCE 10.00 CONST.TAX
may in an ay accrue gains[ said City in consequence of the
granting rspcn I MECH.CONT. LIC.NO. MECH.
�Q l to��n_t9J TOTAL TOTAL
U�im_cc I
' Signa are of App want onlraclor Date
OFFICE COPY