9264 APPLICANT TO FILL'IN INFORMATION W N RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON / PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS' - BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 9264
OWNER'S PLAN CHECK VALIDATION
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NAM• P ONE OTY. ELECTRIC PERMIT FEE
cox AcroRs
OUTLETS-SWITCHES-RECEP 10.00/1.00 -✓V Y.�C�
N
uc.No. LIGHTING FIXTURES 10.00/1,00
'ONT ACTOR's ,[ �d APPLIANCES-RESIDENTIAL 4.00
AD ESS -A IlCr VI
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECTPANELS (OVER 200 AMP) 20.66 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.SS ENG. SPECIAL CIRCUIT 5,60 PERT VALIDATION
ADDRESS CAVA
ZIP EMP.METER OR POLE INS. 20.00
ADDRESSrs MOTORS SEE FEE SCH. JUL 121985
ADDRESS /� J(`
SERVICE CHANGE 20.00
0 O o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 C(ry Of/LUpe�I�
I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE AT 0
wQ H (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. L MECH.
H w z Professions Code.//IInd�����W4}}��yyL�nse is in full fur
z o e2 - License Class_L..��so Lie Number ❑ ❑ ❑
o w F Date Contract.,
a` y 2 BUILDIN PERMIT
BE Ic w u OWNER-BUILDER DECLARATION INFORMATION
oa MISC.- REFER TO ORD
E:
; u H I hereby affirm that I am exempt from the Contractors License VALUATION $/FT.
u o¢ Law for the fallowing reason.(Sea 7031.5,Business and Professions PERMIT ISSUANCE 10.00
rwto Code:Anycily urcounty whichreyuiresapermit to construct,alter,
IS U Q 2O Improve,demolish,Or repair any structure,lire,prior to Its Issuance,also ELEC.CONTR. LIC.NO. ELEC.
0 a, requires the applicant for such permit to file a signed statement that TOTAL E MIT TO
Es
$w he is licensed pursuant to the provisions of the Contractor's License
HZ >0 Law(Chapter 9(commencing`uith Section 7000)of Division 3 ofthe CIO
i o Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
IS H the basis for Ore alleged exemption.Any violation of Section 7031.5 ST RIES YPE 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(8500).):
❑ I,as owner of the properly,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 (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.06 S0.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
meets are not intended or offered for sale if,however.the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner. GAS-EASYSTEM-OVER 4(EA) 2.00 BUILDING USE
builder will have the burden of proving that h . .
e did nut build or it.- IND' CON PB Omer
prove for purpose:of Sale.). INDUSTRIAL WASTE INTER. 30.00
O 1,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 ASSESSOR.PARCEL U.
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 contractions)licensed pursuant to SEWER-SANITARY-STORM EA.2001t/1 0.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ 1 ant exempt under See. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE No.
WORK EHS'COMPI:NSA1'ION DECLARATION T WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified'
copy thereof'ISec.3800.Lab.CJ. du
Policy No. output _
Q p CggtilieJ co I he ted FIRE SPRINK ENERGY T-24
Z Z m/Certified iI pection division. MISC.- REFER TO ORD.
O Applicant_ - V❑ N❑ V ❑ N❑
� y CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LLI >_ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
(LO This vection need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
=) Z hundred dollars 1$100)of less.) [
U O 1 certify that in the performance of the work I'.,wh1Wl this per. CITY. 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'Compensation Laws of California. BUILDING
UED Date Applicant ALTER OR ADD TO MECH. 5.00
>, to
Q. NOTICE TO APPLICANT: If,after making this Certificate o&Ex-
F Z empoon,you should become subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shut be deemed revoked. AIR HANDLING UNIT(TO IO)MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hmeiby affirm Omt 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 UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certify that l leve read this application and state that tem above VENTILATION FAN (SINGLE) 4.00
•
information is correct.I agree to comply with ul1 city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.1 6.00 PLUMBING
ordinances and state laws relating t. building construction, and
hereby authorivc representatives of this city t. 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 ny viz /y rue .gainst;aid City in con quer a of the PERMIT ISSUANCE 10.00
ST.
mg f ll' Cra, MECH,CONT, LIC.NO. MECH.
TOTAL TOTAL
R oc of 1¢arO/Commet., Title
OFFICE COPY