09645 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BAL POINT PEN ONLY
BULLpI NG PROJECT I DENTI FICAT� PERMIT NUMBER
Bu ,NG APPLICATION & PER O
U4e E55
OHO K/ 4a BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME CITY. ELECTRIC PERMIT FEE
• �Bi./7s�N C ry vHONE
NAME NAME UTLETS-SWITCHES-RECEP 10.00/1.0
���G1'Ii P LIc.No. / LIGHTING FIXTURES 10.00/1.00
DnrRAcruR's
ADDRESS APPLIANCES RESIDENTIAL 4.00
Ac (yam.
t/7 <S� � PMpN 6y- PANELS 10.00 DATE OF APPLICATION
RCNITECi PANELS (OVER 200 AMPI 20.00 PLAN CHECK FEE P.C.NO.
OR
O
ENGINEER
LIc,NO, SIGNS TRANS. 3.00
ADDRESS ENO' SPECIAL CIRCUIT 5,00 FERMI _M L)ON
ZIP EMP. METER OR POLE INS. 20.00 AUG_ML
APPLICANTS MOTORS SEE FEE SCH. A 2 0 19$6
ADDRESS
SERVICE CHANGE 20.00
0 0 o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 City of Cupertino
<u U I hereby uft'irn that I atm licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and BLDG. ELEC PLG. MECH.
Fm i Professions Code,ay)q, license is in full fore 1 ff ❑ ❑ ❑
z o w - License Cla s 4/ I ic.Number
Z w Uate , rl 'r Contractor tl
a r s BUILDING PERMIT
¢ ¢ w 4 OWNER-BUILDER DECLARATION INFORMATION
n 0aw MISC. REFER TO ORD
w 1 hereby al firm that I am exempt from the Contractor's License VALUATION
F LL O j Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city Crummy which requires a permit to construct,alter,
QQ¢Q Improve,demolish,or repair any structure,prior to Its issuance,also ELEC.CONTE, LIQ NO. ELEC..
ar
O¢ requires the applicant for such permit to file a signed statement that TOTA PERTO
w m LL he is licensed pursuant to the provisions of the Contractor's License
PERI�
Fzr Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe C
ce I
< Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
/�@
¢ r$ the basis for the alleged exemption.Any violation of$e<lion 7031.5 STORIES TYPE CONSTR.
by any ipplicamfor a permit subjects the applicant too civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(S50OL).
❑ I,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 Low 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
mere,
himself or through his own employees.Provided that such imPrdve-
mmselfonobinill Itis r con'l.yees, la If,however,uthe bullding GAS-EA.SYSTEM-11NC.4OUTLETS 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 inI-
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ 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 contraclons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under Sea ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Came; Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPE:NSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of conunt to wit-Dame. ZONING
or a cerlificate of Workers'Compensation Insurance,or a certified
ENG.SITE NO.
copy t Is erect l Sec.3800,Lab.C.
Policy No. C.nlponyF'�t� �NS
O Certified copy hereby furnishe FIRE SPRINK ENERGY T-24
Z Z �Cerr p t i c ty ins n division. MISC.- REFER TO ORD. Y N Y N
Q Applicant's ❑ ❑ ❑ ❑
i N CER1'1FICA'1'1!01'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
>_ COMPI?NSAT'ION INSURANCE PLG.CONTE. LIC.NO. PLG.
d O (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
Z) Z handled dollars(SI00)or ins.)
U O 1 certify(flat in the pertormunce of the work for which Wis per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
ED Dale Applicant BUILDING
0. pp ALTER OR ADD TO MECH- 5.00
} N NOTICE TO APPLICANT. If,after making this Certificate of Ex-
F Z craidi n,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 10=C.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. 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
1 certify That I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• information is cornet.I agree to comply with all city and county PLUMBING
ordinances and gate laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.1 6.00
hereby authorise representatives of this city to enter upon the BOILER-COMP (Over 100,000BTU)SEE FEESCH. MECHANICAL
i above enriched 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 any way accrue ag;' t said City in consequence of the
grunting. spe lit. MECH.CONT. LIG NO. MECH. /
�� I TOTAL TOTAL
Signature of Applicant/Contractor Date
OFFICE COPY
t