14159 APPLIQANT TO FILL IN INFO ATION WITHIN RED LINES - USE J - ' L POINT PEN ONLY
- BUILDING PROJECT I DENTI FICA PERMIT NUMBER
BUILDING APPLICATION & PE IT
ADDRESS �v l�� 6/� 1415 9
UILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNFR'S gam PLAN CHECK VALIDATION
NAME /�///yy//AA 73�.-� CITY. ELECTRIC PERMIT FEE
&OiE�1.y. PHONE
CONTRACTORS
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO. LIGHTING FIXTURES 10.00/1.00
AADDRESS TORS - APPLIANCES-RESIDENTIAL 4,00
NTRAC
PHONE PANELS 10,00 DATE OF APPLICATION
ARCHITECT - PANELS (OVER 200 AMP) 20,86 PLAN CHECK FEE P.C.NO.
on
ENGINEER
LIC.No, SIGNS TRANS. 3.00
ADDRESS ENG. PER MJ, VALIDATION
ARCH ESR SPECIAL CIRCUIT 5.00
ZIP EMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE _ ,� 20.00 I I r^ ,(()
o o LICENSED CONTRACTORS DECLARATION k'L`aBt�r b v
aU I hereby affirm that I am licensed under provisions of Chapter 9 -
Z ISSUANCE DATE
I" (commencing with Section 7000)of Division 3 of the Business and
�n¢ A t BLDG. ELECT. PLG. MECH.
0 y i Professions Code,and my liven Lic.N full force and effect. " - ❑
2 D w wo License Class Lin.Number
H w Oate Contractor City of Cupertino
¢ Y s BUILDING PERMIT
W � ¢ OWNER-BUILDER DECLARATION
Ic U INFORMATION
wC i MISC.- REFER TO ORD
; U 1 hereby affirm that I am exempt from the Contractor's License VALUATION
uoj Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00
Ly0 Code:Any city or county which requires a permit to construct,alter,
s In¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
O to requires the applicant for such permit to file a signed statement that TOTAL
o. w$w he is licensed pursuant to the provisions of the Contractor's License PERMITTO
< Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe p
ic Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE TE h/ G'J n
M I- the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant l'or a front subjects the applicant to.civil penally' ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(5500).):
❑ 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,AR EA,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 5.06 So.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve GAS-EA.SVSTEM-I 6.00
mems are not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner- GAS EASYSTEM-OVER 4 (EA) 200
builder will have the burden of proving th - . . .
at he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER30.00 RES IND CON PB Orbe,
❑ I,as owner of the property,am exclusively contracting with . ❑ ❑ 0 0 ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
end 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 forsuch projects witha contmetorts)licensed pursuant to SEWER-SANITARY-STORM .STORM EA200h/10.00
TRACT NO. PARCEL NO.
the n mC ris icense aW.
❑CoI tLs f LSec. ,B.&PEC.hm this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKS RS'COMPENSAT'ION DEC LA RATI N WATER TREATING EQUIP. 5.00
1 hereby affirm tat I have a certificate of consent to scll'.insure, ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or i earl ifie
copy thereof(Sec.3800,Lab.C.).
Policy No: Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is fled with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y❑ N Y ❑ N[3
m PERMIT ISSUANCE 10.00
LU - CERTIFICATE COM 17 SATION INS FROM WORKERS' FLOOD ZONE A.L.U.C.
W COMPutbe oro INSURANCE if the? PLG.CONTR. LIC.NO, PLG. Y� N� Y � N�
M) Z (This section need mot he complete) if the permit is I'or one TOTAL
hundred dollars(5100)or less.)
U O I certify that in the performance of the work for which this per- CITY MECHANICAL PERMIT FEE FEE SUMMARY
LL Y mit 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.
n Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE TO APPLICANT': If,after making this Certificate of Ex-
F Z emption,you should become subject to the Workers'Compensation APPLIANCE 0 PLAN CHECK
e- 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=C.F.M.) 4.
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 100MC.FM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction loading agency for EXHAUST HOOD(WITH DUCT) 5.00
the pertbrmance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ,C.). HEATING UNIT(TO 100,000 B.T.U.) 6.00
Lender's Name HEATING U N IT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
• I certify that I have read this application and state that life above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-OOMP(3 H.P.or 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 SCH. MECHANICAL'
above-mentioned property for inspection purposes.
- (Wc) 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 a rue sins[ s 21 City in Conuquence of the
gran n fp it. CH.CONT. LIC.NO. MECH.
J
TOTAL
Sig [ur Data TOTAL 3d V
Applicant/Con r for - (J j
OFFICE COPY