Loading...
09755 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY PERMIT NUMBER BUILDING PROJECT lDENTIFICATION APPLICATION & PERMIT BUILDING n^ r xADDRESS t 'y 7 d'''f ^ BU DING -ELECTRICAL-PLUMBING-MECHANICAL VV 14iV O R PLAN CHECK VALIDATION NAME ^ QTY. ELECTRIC PERMIT FEE �\ ONF CO e s OUTLETS-SWITCHES-RECEP 10.00/1.00 LIGHTING FIXTURES 10.00/1.00 ro ro CA PPLIANCES-RESIDENTIAL 4.00 ES PHDry PANELS 10.00 DATE APPLICATION ORRCHfTEC PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO. ENGINEER LIC.NO. SIGNS TRANS. 3.00 ADDRESS END SPECIAL CIRCUIT 5.00 PERMIA I ATION P ZIP EMP.METER OR POLE INS. 20.00 PAID APPAPPLICANT MOTORS SEE FEE SCH. SEP 19f�5 v SERVICE CHANGE 20.00 wo o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 ,City OF CII❑Q'.`y IOO c u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE BATE z rw (commencing with Section 7000)of Division 3 of the Business and en a H BLDG. ELECT. L MECH. h F, H z I'rolcssons Cn anJ my license is in full for�•� ff• I } Z O m - I-icense Class c 7 Lia Number - Q r w Datc �QPUntractor � y - I -Q7 a y f BUILDING RMIT ¢ ¢ a OWNER-BUIL DECLARATION A o a v INFORMATION w 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION $/FT. F ¢ Oa Law Codc forthecitylowinglitywhch c.requires a perminess t to Professions PERMIT ISSUANCE 10.00 Code:Any city erectility rep which requirese O rior to construct,alter, Qcr 0 improve, or repair any structure.prior to 115 issuance.also ELEC.CONTR. LIC.NO. ELEC. d O¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO a w m he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9(contmencimg with Section 7000)of Division 3 oldie ❑ilsiness and Professions Code)or that he is exempt therefrom Ind QTY. PLUMBING PERMIT FEE ¢ F$ the basis for the alleged exnnptlun.Any violation of Section 7031.$ STO IES PE CONSTR. T by any applicant for a permit subjects Ore applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00 of not more than five hundred dollar,(5500L): ❑ 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 SO,FT.FLOOR AREA TOTAL ACREAGE himself or through his own employees,provided that suchimprove - mentsarenotintendedOroffered for sale.If,however,thebuilding GAS-EA.SYSTEM-1INC.40UTLETS 6.00 or improvement is sold within one year of completion, the owner- builder will have the burden of proving that he did not build Mel- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE RES IND CON PB Other prove 1,as o nee of the p INDUSTRIAL WASTE INTER. 30.00 0 ❑ ❑ ❑ E] ❑ I,as owner of the property,am exclusively contacting 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:"rhe 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 coinractorts)licensed pursuant to SEWER-SAN V-STORM EA.200ft/10.00 ° the Contractor's License Law. TRACT NO. PARCEL NO. ❑ l am exempt under See ,B.&P.C.for this WATER HEATER W/VENT 6.00 reason Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO. WORK FRS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 I hereby alwn 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 thereof(Sec.3800,Lab.C.). Policy No. Company ❑ Certified copy is hereby furnished. Z Z de ith t yy Cei ed copy � h city ins ction division. FIRE SPgINK ENERGY TI4 L ,tfa, Iica f MISC.- REFER TO ORD. Y E] NEl Y E] NE] � N CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 In FLOOD ZONE A.L.U.C. LU COMPISNSATION INSURANCE PLG.C NT LIC.NO. PLG. Y N V EICL Z ('Phis section need not be completed if the permit is for one r TAL 0 N hundred dollars(81001 airless.) U O I certify that in Ole performance of the work for which this per- QTY. � ANICAL PERMIT FEE FEE SUMMARY LL mit is issued, I shall not employ any person in any manner an as to Ubecame subject to the Workeri Compensa Nun Laws of California. D. Date Applicant BUILDING >_ w NOTICE TO APPLICANT': If,after making this Certificate of Fs- ALTER OR ADD TO MECH. 5.00 F ? emplion,you should become subject to the Workers Compcasallot 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 10,00DC.F.M.) 4.00 CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE I hereby affirm that there is a construction Irndit,agency for EXHAUST HOOD (WITH DUCT) 5.00 the performance of the work for which this permit is issued(Sec. MICROFILM ; 3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 Lender's Address ELECTRIC I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 information is correct.I agree to comply with all city and con6mY PLUMBING ordinances and state laws relating to building construction, and BOILER-COMPOH.P.or100,000B.T.U.) 6.00 hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. gQILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL (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 consculuence of the •rani g of this p m t MECH.CONT. LIG NO. MECH. TOTAL TOTAL ,,nature ppnnl ontraclor Date ' INSPECTOR COPY I APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION PERMIT NUMBER X BUILDING APPLICATION & PERMIT ADDRESS r� BU DING -ELECTRICAL-PLUMBING-MECHANICAL A`�O 9 7 5 IO OwrvER' PLAN CHECK VALIDATION NAME DTV. ELECTRIC PERMIT FEE HONE �f Co ER s �1 OUTLETS-SWITCHES-RECEP 10.00/1,00 - I/ 7 c.rv°.I of LIGHTING FIXTURES 10.00/1.00 D VA ro To To PPLIANCES,-RESIDENTIAL 4.00 7. 1 3on PHONE PANELS 10,00 GATE OF APPLICATION OORRCHITEC PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO. ENGINEER 41C.NO. SIGNS TRANS. 3.00 ARCH.OR ENG. PERMIT VALIDATION ADDRESS SPECIALCIRCUIT 5.00 ZIP EMP.METER OR POLE INS. 20.00 paQ' APPLICANTS MOTORS - SEE FEE SCH, ADDRESS CCD .E n 1985 SERVICE CHANGE 20.00 Gw ,02 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30,00 City Of Cupertino v I hereby affirm that 1 am licensed under provisions of Chapter 9 IOO G i ISSUANCE ATE (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. L MECH. F N zo Professions C ndJJ����y license is in full for def ❑ ❑ v ❑ zo z w o License Class _(�_LpLic:Numb, CJTO r w r UI- ntractor IS IS w OWNER-BUILDER DECLARATION BUILDING RMIT o A INFORMATION . - w g a- H I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO OR H U m J Law For tin following reason.(Sec,7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION /FT. Code:Any cityor county which requires a permit to construct,alter, ELEC.CONTR. - LIC.NO. IS S, ¢Q improve,demolish,or repair any structure,prior to its issuance,also ELEC. u w m u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO he is licensed pursuant to the provisions of the Contractor's License r z i Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe E 4 o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT •' FEE I- m the basis for the all,ged exemption.Any violation of Section 7031.5 STO IES T PE CONSTR. a3 _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00 of not more than five hundred dollars($500).): ❑ 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 sm ct re 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 5G.FT.FLOOR AREA TOTAL ACREAGE • himself or through his own employees,provided that such ine fum C. ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1INC.4,OUTLETS 6.00 or improvement Is sold within one year of completion, the owner- builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE prove for purpose of stied' INDUSTRIAL WASTE INTER. - 30.00 RES IND 11 PB oroar LEl F-1 ❑ as owner of the property,he exclusively contracting with El El licensed contractors: 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 Does not apply to antr owner of property who builds t r improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 confronts Contractor's h projects with a cnntraclor(s)liccnsed purslmnt to the Comractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO. ❑ I am exempt under Sec. ,BARC.for this WATER HEATER W/VENT 6.00 reason Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO. WORK ERS'COMPENSAT ION DECLARATION WATER TREATING EQUIP. 5.00 I hereby a11ina that I have a certificate of consent to self-insure, or a vcnificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO. copy thereof fSec.3800,Lab,C.). Policy No. Company -❑ Ce ificd copy is hereby furnished. z X10 Ce . copy Ile III the city ins ft.ion division. FIRESPRINK ENERGY T-24 F O.s Pplicu (* MISC.- REFER TO ORD. Y [D N❑ Y ❑ NE3 c m CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C. LU COMPENSATION INSURANCE PL .C r IC.N PLG. CL Z fThis section need not be completed if the permit is for one O TAL 0, / Y❑ N Y F-1N D U O 'hundred dollars IS 100)or less.) I certify that in the performance of the work for which Otis per QTY ANICAL PERMIT FEE FEE SUMMARY LL F out is issued,I shall not employ any person in any anon,so as m Ow become subject to the Workers'Compensation Laws of California. IL D'at, Applicant ALTER OR ADD TO MECH. 5.00 BUILDING } Ml NOTICE: TO APPLICANT: If,after making this Ce Hificute of Ex- ♦- ? eruption,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 10,000C.F.M.) 4.00 ' CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER10A00C.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(See. MICROFILM 3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 Lender's Address ELECTRIC 1 certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00 information is correct. I agree to comply with all city and county PLUMBING ordinances and slate laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00 hereby authorize representatives ins inspection This city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL above-mentioned property forinsp of 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 ocer a ag ' st said ity in consequence of the n gofthis 9 ECH.CONT. LIC.NO. MECH. � !`8 TOTAL TOTAL Signature of Appl ant/Contractor Date / OFFICE COPY