11234 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FICA PERMIT NUMBER
IRAQ ING - APPLICATION & PET
A9DRE55 11, 234
UILDING-ELECTRICAL-PLUMBING-MECHANICAL
WNEH PLAN CHECK VALIDATION
•� NAME /I(/�_ /%��/
O
� PRNE ELECTRIC PERMIT FEE
CONTRACTOR - UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
LIC.ND. LIGHTING FIXTURES 10.00/1.00
ADDR's
ADDRESS PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 2000 PLAN CHECK FEE P.C.NO..
OR
ENGINEER
LIC.No, SIGNS TRANS. 3.00
ARCR,OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 20.00 `
APPLICANTS MOTORS SEE FEE SCH. ✓IC ,liP `�
ADDRESS
SERVICE CHANGE
D .00
o
oLICENSED CONTRACTORS DECLARATION p
u u I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
< y (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H
,z Professions Code,and my license is in full force and effect. ❑ ❑' 1:1z o m- License Class Lie.Number
9 N L °w Date Contractor City of Cupertino
a mBUILDING PERMIT
o: w u OWNER-BUILDER DECLARATION INFORMATION
w3: d y 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
a. o Q Law to,the following reason.(Sec 7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
r N0LI Code:Anychy orcounty which requires a permit to construct,alter,
Qp improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
DLL requires the applicant for such permit to file a signed statement that TOTAL PE-RMMIT TO
w $•� he is licensed pursuant to the provisions of the Contractor's License
Law(Chapter 9(commencing with Section 7000)of Division 3 of01e
iD Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
M F-o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
L. by any applicant fora permitSubjects the applicant to a civil penalty gLTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500)J)
❑ 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 Contractor's License Law does not apply to an owner of
• property who hailds or improves thereon,and who docSsach work IFIXTURES-PER TRAP 5.00 SD.FT.FLOORAREA TOTALACREADE
himself or through his awn employees,provided that such improve-
mesarenot intended or offered for sale.if,however,the building GAS-EA.SVSTEM
nt -I INC.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 he did not build or m- RES IND CON Pa Other
prove for purpose of silo.). INDUSTRIAL WASTE INTER. 30.00 El ❑ El El 13❑ 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 ASSESSORSPARCEL 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 contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ 'am crept mu` c. ,BAP.C.I'or this WATER HEATER W/VENT 6.00
`/ rensun -
//� Owner Ume WATER SYSTEM 6.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPF-NSATION D17CLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO,
or a certificate of Workers'Compensation Insurance,or a.c.Crtified
Copy thereof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRESPRINK ENERGY T 24
Z Z Cl Certified copy is riled with the city inspection division. MISC.- REFER TO ORD.
O Applicant V❑ N❑ V ❑ N❑
~ in PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU 1 CIiRTIFI CLOMP NKATIOT EXEMPTFROION
LU COMPENSATION INSURANCE PLG.CONTR. LIC.N0. PLG. Y❑ N❑ Y ❑ N❑
1 O (This Sect It need not be completed if the permit is for one TOTAL
CJ Z hundred that
IS 100)pe less)
U O I Certify trim in the performance of the work for which this Per- DTY 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 Workers'Com pe Diet ion Laws of California. BUILDING
0 y Date-Applicant ALTER OR ADD TO MECH. 5.00
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex-
2 emption,you should become subject m 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 10,0WC.F.M.) 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 HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
. I certify that l have read thisapp(kation antistatic that theabove VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating 10 building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000STU)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 in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
gran[i of this pe it. NONT
�, MEC .C . - LIC.NO. MECH.
f jJ / G- TOTAL TOTAL
Signmure e A p enol Cuntmclor Dale 9
OFFICE COPY -