09567 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT 09567
ADDRESS t
--I QL1 BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
O A ED'S PLAN CHECK VALIDATION
NAM
5 OTY. ELECTRIC PERMIT FEE
Ns
CONTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
M ,,II •�
uc.NO.`110���� LIGHTING FIXTURES 10.00/1.00
CONTRACTOR s �R PPLIANCES-RESIDENTIAL 4.00
A9, PRONE-7-T-7-CG-r(0
PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.No. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5,00 PERMIT /'
Ip,y�w
ARCH E55
ZIP TEMP.METER OR POLE INS. 20.00 A'
APPLI ANTS MOTORS SEE FEE SCH. AOV n O�
ADORESS I C
SERVICE CHANGE �20.00 /�
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 CRY Of Cupertino
a u b I hereby affirm that I am licensed trader provisions of Chapter 9 ISSUANCE DATE
h Q w (commencing with Section 7000)of Division 3 0l the Business and BLDG. ELECT. PLG. X
ProessionsClicense is in fullV�zoLianscClass Lic.Numhcr LOEl 1:1o BUILDING PERM
Ie w u OWNER-BUILDER DECLARATION -
w 3 LL r 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD INFORMATION
uoa Law
for the following reason.(Sec.7031.5,Be,inessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
L" -o Code:Any city or county which requires permit to construct,alter,
Qa,Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
O C requires the applicant for such permit to file a signed statement that TOTAL gMIT TO
w$ he is licensed pursuant to ole provisions of the Contractor's License
Hzi
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
a Business and Professlow Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
es the basis for the alleged exemption.Any violation of$ection 7031.5 STORIES TYPE CONSTR.
a- by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars(S5001.):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
their sole compensation,will do the work,and the struclure is not OCC.GROUP RES.UNITS /
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 ll
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 re through his own employees.provided that such inmfove-
mmself o not intended or nfl'creoyee sale.if.ed that such
he building GAS-EA.SYSTEM-1 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 im-
provefor purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 S IND CON PB Oma.
❑ 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 Of imProveS thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
the Cont for such License
ts Lwifilucontmdorl s)liccnscd pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ Iran exempt under Scc. ,B.&PEC.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACG FILE NO.
WORK ERS'COMPENSA EON DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm thal I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certil ica of Workers' ora tion Insu nee,oryry erlilr
copy t h .I P(l�ieC�
PolicY p
O ❑ Certified copy is hereby furnished FIRE SPRINK ENERGY T 24
Z 2 ❑ Certifie o y is Bled wits the jity inspection division. MISC.- REFER TO ORD.
O Applicant (_��•- Y❑ N❑ y ❑ NE]
MrA CERTIFICA'I'I;OF EXEMPTION FROM W01FRS' PERMIT ISSUANCE 10.00 FLOOD ZONE a.L.u.c.
LID > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. v❑ N❑ Y❑ NE)
❑ ('Phis section need not he c repleted if the permit is for one TOTAL
Z) Z hundred dollars IS 100)or less.)
U O 1 certil,that in file performance of the work for which this per- CITY. MECHANICAL PERMIT EE FEE SUMMARY
LL f mit is issued,I shall not employ any person in any nim ncr sn as to e
U become subject to the Workeri Compensation Laws of California. 1-43
> a Dutc Applicant ALTER OR ADD TO MEC � 0 BUILDING
} m NOTICE TO APPLICANT: IL after making this Certificate of 1!x %-
F-. ? emption,you should become subject to the Workers'Compensation APPLIANCE 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)000C.F.M . 0
CONS'T'RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER loMaF.M.) 6.0 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,Co.C.). HEATING UNIT(TO 100,000 B.T.U.) 9.00
Lender's Name HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lenders Address
I artily that I have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00
information is carred. I agree twith all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and slate laws relatingg comply building construction, and
hereby authorise representatives of this city to 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 in any way accrue against Said City in consequence of the PERMIT ISSUANCE 10.00
gN t O( 1 s Tplit. MECH.MECH.CONT. LIC.NO.
_ gS TOTAL TOTAL
Signature of ApplicantlContraclor Dale (lv
OFFICE COPY