10967 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL..P.OINT PEN ONLY
BUIL ING PROJECT IDENTIFICATION - - - PERMIT NUMBER
�. BGIEDING APPLICATION & PERMIT O
ADDREss BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
Ow EP'S - - PLAN CHECK VALIDATION
-�� NAME QTY. ELECTRIC PERMIT FEE
iii QAAA� PHONE
CON ACTOR'S
NAME pp. ^ OUTLETS-SWITCHES-RECEP 10.00/1.00
AL/AeLp Q14A uc.No. 3 �E�^�7� LIGHTING FIXTURES 10.00/1.00 0
�( , N croRs $T - APPLIANCES-RESIDENTIAL 4.00
AovR ss /r 4 f
l - W PHONE -Z-? , PANELS _ 10.00DATE OF APPLICATION
. A LRITECT ,PLAN CHECK FEE P.C.N0,
OR
PANELS 200 AMP) 20.00
ENGINEER
• LIC.rvo. ISIGNSTRANS. 3.00
ARCHOnPERMIT VALIDATION
' ADDRESS ErvO , 4' ' ' SPECIAL CIRCUIT 5.00 r
• - ZIP EMP.METER OR POLE INS. 20.00 '
APrucANrs - MOTORS SEE FEE SCH,
SERVICE CHANG ••'20.00
'woo .LICFNSED CONTRACTORS DECLARATION Y/
< v 1 hereby affirm that I am licensed under provisions of Chapter 9 4 .+ jt+ ISSUANCE GATE
Q w (commencing will,Section 7000)of Division 3o the Business and BLDG. ELECT. PLG. MECH.
H w w Professions Code,and my license is in full force and effect. El
0 w License Class _ Lie.Number
Dale Contractor City of Cupertino-
Y BUILDING PERMIT ,
to w OWNER-BUILDER RBUILDI)R DECLARATION INFORMATION
I'xu ;LL N I hereby affum that I am exempt from the Contractor's License MISC.= REFER TO ORD
w 0' 04 Law forthe followmaremon.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE - 10._00 0Got, _VALUATION7 $/FT.
Code:Any city or county which requires a peril to construct,alter,
r ar ¢ improve,demolish;,nr repair any structure,prior 10 its issuance,also ELEC.CONTR. LIC.NQ _ ELEC. �Q
e wO e, requires the applicant for such permit to file a signed statement that - TOTAL PERMIT TO'
m he is licensed pursuant to the provisions of the Contractor'sLicense _
H z i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a Business and Professions Code)or that.he.is exempt therefrom and OTY . PLUMBING'PERMIT FEE.
,¢ F m the basis for the alleged exemption.Any violation of Section 7031.5 >STORIES TYPE CONSTR..
by any applicant for a permit subjects the applicant-to a civil penalty ALTER-DRAIN (EA) 5.00
of not more than five hundred dollars(5500) - .
.): i
❑ 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'nffered for sale(Sec. 7044, Business and Professiofns DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner o
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP ' ' '5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees,provided that such ibuildi v ;
hicnits mself a throngiot his or employeeffered for sale.lf,ed that such
building GAS-'EA.SYSTEM-11NC.4OUTLETS 6.00
or improvement is sold within one year of completion, the own cry GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or int BUILDING USE
RES IND. CON
1,aso PB Other
prove nee m of sale.). : INDUSTRIAL WASTE INTER. 30.00 1:1 ❑ Il. El 1:1❑ I,as owner of the'property,uexclusively contracting with
licensed contmetors to construct the project(Sec.7044,Business , LAWN SPRINKLERS-1 INC 5 V.B. _ 6.00 ASSESSORS PARCEL NO.
+ and Professions Code:"f lie Contractor's License Law docs 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 contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
file Contractor's License Law. TRACT NO. PARCEL NO.
1 I atm exempt under Sec. ,BAP.C.for this WATER HEATER W/VENT - 6.00 '
reason
Owner - Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
'WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 "
I hereby affirm that I hdva a certificate olconsent to self-insure, '^ ,
or a certificate of Workers'Conmensation Insurance,or a certified A' ZONING ENG.SITE NO.
copy ther_epf(Sce.3800,Lab.C.).
Policy N O CyymLany_
O ❑ Certified cop Is7 eb�(yr Is
r FIRE PRINK - ENERGY.T-24
Z 2 ❑' Certifi,�1 olry..y5..f1•ewJ lw�it�h,Lh y 'n t�an/division. MISC..- REFER TO ORD:
. F D ApPicunl_1��V '�iY4+•�•H-f--+.Q1Y10_P'J�W._r--- V❑� N❑ Y ❑ N❑
CCN CIi R'I'IFICATI OF EXFiMPTION FROM WORKI:RS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU I COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG, _
CL ❑ , '(This section need'not be conmleted if (lie permit is for one IOTA ILLV❑ No Y ❑, N❑
7.2 It u edred dol tars IS 100)or less.) -
U O' I certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE .FEE SUMMARY
LL f- miL is'issued.I'shall not employ any person in any manner so as to
O W become subject to the Workers Compensation Laws of California.
a Datc Applicant " ALTER OR ADD TO MECH. 5.00 BUILDING
}.m NOTIC17 TO APPLICANT: If,alter making this Certificate of fix- .
F ? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code,.you must forthwith comply will, FEE
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=11F.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„Civ.CJ. _ HEATING UNIT(TO 100,000 B.T.W 8.00
Lender's Name - - HEATI NG UN IT(OV E R 100,000 B.T.U.)9.50
Lender's Address ELECTRIC /
I cantly that I have read this application and state that the above V ENTILATIO N.FAN (SINGLE) 4.00
information nfis is state l I agree 1.ti comply with all city and county PLUMBING
t ordinances and state lows relating'to-building construction, and BOILER-COMP(3 H.P.DF 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP Over 100,000 BTU)SEE FEE$CH. MECHANICAL
above-mentioned property for.inspection purposes.,,'
(We) agre`c to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costa and expenses which CONST.TAX
in any way accrue against said City in conserjuence of the PERMIT ISSUANCE ' 10.00
genng nt it. - MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL'
SI nam ('Applicant/Contractor
Dat" - s ,.,
OFFICE COPY