9275 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMSER
I BOILOING APPLICATION & PERMIT
•.l ADDRESS 9275 2 7 5
rIn- BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER PLAN CHECK VALIDATION
'•- ` NAME •CITY. ELECTRIC PERMIT FEE
�RPHONE
cANTRac7DRs ( UTLETS-SWITCHES-RECEP 10,00/1.00
NAME x
�LQ�TI.-• LIC.No.39 3 LIGHTING FIXTURES 10.00/1.00
cONTRACTORs APPLIANCES-RESIDENTIAL 4.00
AOORE55
i175REHOft PH NE PANELS 14.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT F 5.00 PA10
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS SERVICE CHANGE 20.00 JUL 1 1��g
w 0 o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
re U
MAO!E Cupertino
u hereby ffirm Ill.[ Iam licensed underprovisions of Chapter 9
DATE
m4% (commencing with Section 7000)of Division 3 of the Business and - BLDG. ELEC P G. M CH
O z Professions Co �rld my license is in full for<�eyy
O n - Liclgsg[la ` Lin.Number
9H Du c Cnnt malar
i y. BUILIDING PERMIT
EE E, ec o OWNFR-BUILDER DECLARATION INFORMATION
sa o - ORD
La
u-
0
I hereby affirm that I am exempt from the Contractor's License MISC. EFER TO
04 Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
L• - Code:Anycity or County which requirese permit to construct,after,
Qor Q 00 Improve,demolish,or repair any structure,prior to BS Issuance,aI60 ELEC.CONTR. LIG.NO. ELEC. /�
- DLL rcqui¢s the applicant for such permit to file a signed stwemcnl Ihut TOTAL/l- PERMIT T
n w m he is licensed pursuant to the provisions of the Contractor's License
H z i Law(Chapter 9(commereingwith Section 7000)of Division 3 cfthe
- a Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
ac o the basis for the alleged exemption.Any violation of Section 703 L5 STORIES, PEC $Tfl,
i ;m by any applicant fora permit subjects Ole applicant to a civil penalty ALTER-DRAIN&YEN -WATER (EA.) 5.00
of not more than five hundred dollars(S5001.): i
Cl I,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 4.00 OCC. RO RES.UNITS
their sole compensation, Ib
will do e 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 doe,such work FIXTURES-PER TRA 5.00zm4 SD.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improvc-
meritsarenotintendedorofferect for sale,If,however,the building GAS-EA.SYSTEM-11 C.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-O ER 4 (EA.) 2.00 BUILDING USE
t builder will have the burden of proving that he did not build or im- R IND CON PB Omer
prove for purpose of sale.). I N DUSTRI AL WASTEI TER. 30.00
❑ I,as owner of the property,on exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:T'hc Contractor's License Luw Joes not apply
to an owner of property who builds or improves thereon,anJ who LAWN SPRINKLERS- VER 5 IEA.) 1.00
or f
contracts such projects with a ttmtraarl
os)licensed 11.1-.1.1the Contractor's for License Law. to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
Cl lam exempt under Sec. ,B.&EC.for this WATER HEATER W/V NT 6.00
reason
Owner Dane WATER SYSTEM 5.00
ACC.GATE ACG FILE NO.
WORK 1iRS'COMPENSAT ION DECLARATION WATER TREATING E UIP. 5.00
I hereby affirm that I have a certificate of consent to sell'-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance.or a certit'ied
copy thereof(See.3800,Lab.C {.�F -l�
policy No. Company .If1C17-1-__I_l._ �1CA-
U Cl Certified copy is I b banished. FIRE SPRINK ENERGY T-24
Z Z 'tied copy Is e h If cit spytim division. MISC.- REFER TO ORD.
(] pplic' Y ❑ N Y ❑ N❑
ir W C.RTIFICA'I'F:OP EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU D COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
IL O ffhis section need not be completed if Ilia permit is for one TOTAL Y❑ N❑ Y ❑ N❑
Z) Z If u ndred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PER FE 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.
of Date Applicant I
a ALTER OR ADD TO MECH. 5.00 BUILDING
} m NOTICE TO Should
become
If,inter making this rs'Compe of Iix-
H Z emption,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=CF.M,) 4.00
CONSTRUCTION LENDING ACENCY AIR HANDLING UNIT(OVER 10,000C.F.M.) 6.00 SEISMIC FEE
I hereby aflinn that there is u 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(T0 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
' x I certify that 1 hove read this application and state that tie above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city andcounty
PLUMBING
ordinances and slate laws rclefng to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
4 hereby authorize representatives of this City to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. CHANICAL
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 PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of life
granting ofthis perm MECH.CONT. LIC.NO. MECH.
+t TOTAL TOTAL
Sig ol anC /
urepplic
o actor Date
OFFICE COPY