8461 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATI ON PERMIT NUMBER
9ILulNG_ APPLICATION & PERMIT g 461
AU ILOIN
T O BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
/ OWNER'SF PLAN CHECK VALIDATION
•'ri NAME n� OTY. ELECTRIC PERMIT FEE
NONE
corvTRACTORsUTLETS-SWITCHES-RECEP 10.00/1.00
NAME //
LIC.NO / Q6 LIGHTING FIXTURES 10.00/1.00 19
CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00 01
AD $4)�//7
// ,'TA PHON4O PANELS 10.00 DATE Of APPLICATION
ARCHITECTPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC,NO SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. 20.00 ^ //
ASMOTORS SEE FEE SCH.
ADDRESS G/A/
SERVICECHANGE P,!%,`,„ 20.00
02 LICENSIiD CONTRACTORS DECLARATION TEMP.POLE `' 30.00
m v I hereby affirm that I am licensed under previsions of Chaptc,9 H f )jiir) ISSUANCE DATE
HQ h (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F H z Professions CodrAn )license is in full forryjlrl19
❑ � ❑ ❑
0 o u, - License C s C� Lic.Number�..7�f� City of Cupertino
O H O )ale Conlmclor
¢ x s BUILDING PERMIT
c w ¢• OWNER-BUILDER DECLARATION
MISC.- REFER TO ORD INFORMATION
K
LL I hereby affirm that 1 am exempt from the Contractor's License VALUATION SIFT.
LL o¢ Law for the following reason(Sea 7031.5.Business and Professions -PERMIT ISSUANCE X0.60
- 0Code:Any cilyorcounty which requires a permit to construct,alter,
¢ a 2 improve,demolish,or repair any structure,prior to its issuance,also ELEG.CONTR. LIC.NO. ELEG
-O LL requires the applicant for such permit to file a signed statement that TOTAL PERMITTO
' w
i he is licensed pursuant to the provisions of the Contractor's License 6GCz7
r z
Law(Chapter 9(commencingwiol Section 7000)of Division 3 ofthc
4 o DTV. PLUMBING PERMIT FEE
Business and Professions Code)or that he is exempt therefrom and
Ic H o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a ; m by any applicant for a permit subjects the applicant Ina civil penalty ALTER-DRAIN -WATER IEA.) $.00
of not more than five hundred dollars(8500).):
❑ 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 Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE
• himself re through his own employees,provided that such improve-
inc!oshimself
are not through his or offered employees,
or provided that s chthe building GAS-EA.SVSTEM-I1NC.40UTL ETS 6.00
or improvement is sold within one year of completion,the owner - .- GAS EASYSTEM-OVER 4 I EA.1 2.00
builder will have the harden of proving that he did not build or int- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
❑ 1,as owner ol'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 docs not apply
to an owner of properly who builds or improves thereon.and who iLAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts forsuch projeciswith a contractors)liecnxd pursuant to - - .200fl 10.00
the Contractors License Law. SEWERSANITARYSTORM EA / TRACT NO. PARCEL NO.
❑ tom exempt hinder Sea ,B.&I'.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKS RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affom that I have a certificate of consent to self-insure, ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thercof(Sec.3800,Lab.C.1/
Policy No. Company_',J '27 S
O O Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
z Z Certified yopy x filed illi thg lily ins'pectimh division.
O ApopIicant.�,0)oI j•4� a ] MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
ML6 CI;RTIFICA'FIi OFEXEMPTIONFROMWORKERS' PERMIT ISSUANCE 10.00 FL00020NE A.L.U.C.
UJ COMPENSATION INSURANCE PLG.CONTR. ❑C.NO. PLG,
CL O (This section need not be completed if the permit is for one TOTAL Y❑ B❑ Y ❑ N
::) Z hundred dollars(S 100)or less)
U O I certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL H 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.
n Date ApplicantALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F ? eruption,you should become subject to the Workets Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10j100C.F.M.) 4.00
CONSTRUCTION LIiNDI NG 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
(lie performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) e.00 . MICROFILM
Lender's Name
Address
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information n correct I agree to comply with all city and county PLUMBING
ordinances and sate laws relating m building 4onatrand c, and BOILER-COMPI3 H.P.of 100,000 B.T.U.1 6.00
hereby authorise representatives of this city U elver upon the BQI LER-COMP (Over 100,000 STU)SEE FEE SCH. MECHANICAL
above-mentioned properly 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 WA accrue agams . Id City in consequence of the PERMIT ISSUANCE 10.00
gran i oIIyS ICrm MECH.CONT. LIC.NO. MECH.
TOTAL
Signature of Ap icant/Contractor Darn TOTAL
\ OFFICE COPY
_ I