1094 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONL
BU I LDING PROJECT I DENTIFICATI ON PE 1 UMBER
BUILDING APPLICATION & PERMIT 1094
AD E
BUILDING -ELECTRICAL-PLUMBING -MECHANICAL
OWNER'S J/ PLAN CHECK VALIDATION
NPME J TY. ELECTRIC PERMIT FEE
• Awwhy PH/ ON
mems ACTORS OUTLETS-SWITCHES-RECEP 5.00/1.00 Ro
LIC.NO. LIGHTING FIXTURES 5.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
PCnr,OF, CUPERTINO
PHONE PANELS 5.00 DATE DP APPLICATION
ARCHITECT 1981 SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
- JO LIC.No. SIGNS TRANS. 3.00
ARCH,OR ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDRESS PAIS
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE Al7eyel
ADDRESS
SERVICE CHANGE 10.000.00
W
02 LICENSED CONTRACTORS DECLARATION
a i U I hereby affirm that I am licensed under provisions of Chapter`) ISSUANCE GATE
(commencing with Section 70001 of Division 3 of the Business and BLOC. ELECT. PLG. MECH.
H y i Professions Code,and my license is in full force and effect. ❑ El i o H License Class Lic.Number
O T _ o Dam Contractor
`a , f � BUILDING PERMIT
C, w OWNER-BUILDER DECLARATION INFORMATION
WO a r I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
3 u. IA y p VALUATION $/FT.
Fu Oa Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 6.00
Code:Any city orcounty which requires a permit to construct.alter, DODO
2 rt ¢ p improve,demolish,or repair any sRucture.prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. 3/ (�' 4
C u requires the applicant for such permit to file a signed statement that TOTAL - PERMIT TO
ec w $ he is licensed pursuant to the provisions of the )of
fDivision
ivmrn 3 License
z i Law(Chapterand
Professions
rofo sions Code)or Section is exempt the of om the (I/dN7g$1Mrl'
a Business and Professionsxempt or that he is exempt therefrom and OTY- PLUMBING PERMIT FEE
the basis for the alleged exemption.Any violation of Sec tion malty - STORIES TYPE CONSTR.
by any applicant fore permit subjects the applicant civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than live hundred dollars my employees
v\
❑ 1,as owner at the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES UNITS
their sole compensation,will(S the work,and the structure is not
intended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AR EA,CON D. 4.00 d1b do
aXCode:The Contractor's License Law does not apply to an owner of l
property who buildsimprovesthereon,and who does such work FIXTURES-PER TRAP 4.00 /p` 5D,GT.FLOOR AREA TOTAL ACREAGE
himself through hisis own employees,provided that such improve-
memsare renalintendedoroffend for sole.If,however,the building GAS-EA.SVSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner
GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that Ise did not build or im-
proveforpurposeOfsale.). INDUSTRIAL WASTE INTER. 20.00 R�EsB/,1MD CON PB Omer
I,as owner of the property,on exclusively contracting with f(� El E] ❑ 1:1licensed contractors to construct the project(Sec. 7044.Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractors License Law does not apply
to an owner of property who builds or improves thereon,and who ILAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA, 200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec,-.B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Date yy o WATER SYSTEM 4.00 ACC,DATE ACC.FILE NO.
WORK E RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that 1 have a certificate of consent to sel6insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereoflSec.3800,Lab.C.l.
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY TQ4
Z
❑ Certified copy is riled with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y ❑ N❑ Y ❑ N❑
CC y CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLC.CONTR. LIC.NCL PLG. / L �S Y❑ N❑ Y ❑ N❑
d O This section need not be completed if the permit Is for one TOTAL O
=) 2 hundred dollars(S 100)or less.)
U O 1 certify that in the performance of the work for which this per. CITYMECHANICAL 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.
O La Date Applicant ALTER OR ADD TO MECH. 4,00 BUILDING
} W NOTICE TO APPLICANT'. If,after making this Certificate of Ex-
Z emption,you should become subject to the Workers Compensation APPLIANCE 4.00 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 10,000C.F.M) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE IL
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD IWITH DUCT) 2.00
the performance of the work for which this permit is issued(See. MICROFILM
3097.Civ CA HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's NazC HEATING UNIT(OV ER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC 3/
• I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00 /
information is correct. I agree to comply with all city and county PLUMBING
ordinances and State laws relating to building construction, and BOILER-DOW(3 H.P.Or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over IOQOOOBTUISEE FEESCH. 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 3.00
gra n of thMECH.per it MECH.CONT, LIC.NO.
TOTAL 7 p0 TOTAL 13 of 3 7
nature of Applicant/Contra Date /
OFFICE COPY