09702 APPLICANT TO FILL IN-INFORMATION WITHIN RED LINES -.USE LL POINT PEN ONLY
BUILDING PROJECT I DENTI FI N
' -
PERMIT NUMBER UMBER
APPLICATION & PRKIIT
mU"LOBUILDING—ELECTRICAL—PLUMBING—MECHANICAL OnO
2
AUCHE
OWNERS
♦,.. ' . PLAN CHECK VALIDATION
NAME- !1 QTY, ELECTRIC PERMIT FEE
• NT L CI u 0�^DNE _
CONTRACTORS OUTLETS-SWITCHES=RECEP 10,00/1.00
.�� Ic.No, LIGHTING FIXTURES. 10.00/1.00
r,DNTRACTG 's
APPLIANCES RESIDENTIAL 4.00
aooREss
(G/.I 4 PHONE PANELS - 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER I
-LIC.No. SIGNS TRANS. 3.00 '
ARCH,OR ENG ! SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
Ss
LP.
APPLICANT'S EMP.METER OR POLE INS. 20.00
ADDRESS
DEEss MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
HDoo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
iw I hereby aDirit Thal I n 00)of under n 3 of the of Chapter 9 ISSUANCE DATE
y (commencing with Section 7 ruc i of Division 3 of the Rosiness and
¢y - BLDG. ELECT. PLG. M .
F o z Professions Cyqs((..fi.yn�1�t y license u in Cull for ��{j 1� ❑ ❑ ❑
' 0. -o License Class(,.csCd�Lia Numbc�
F N F j Late Aa:lJ WWFMIL onlmclnr
II ��'',,�� - BUILDING PERMIT
rc ¢ OWNIi R-BUILDI>H DECLARATION
INFORMATION
w ; LL y I hereby affirm that I am exempt from the Contractor's License MISC.— REFER TO ORD
w o ¢ Law for the following reason.(Sea 7031.5,Buvinessm l Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
� — -I Code:Any city orcounly which requires a permit to construct'alter,
'
Qc¢ o improve,demolish,or repair any structure,prior to its issuance,also EIEC.CONTR. LIC.NO. ELEC.
w
Ort requires the applicant for such permit to file a signed slmemeat that - TOTAL PERMIT TO
a w m he Is licensed pursuant to the provisions of the Contractor's License
Hzin Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe
4 er Business and Professions Code)or that he is exempt therefrom slit OTY. PLUMBING PERMIT FEE
or H $ the basis for the alleged exemption.Any violation of Seclion 7031.5 STORIES .TYPE CONSTR.
03 _ 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($500).): -
❑ 1,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 docs oat apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 S0.FT.FLOOR AREA TOTALACREAGE
• himself or through his own employees,provided that such improve-
mems are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00 t
or improvement is sold within one year of completion, the owner- GAS EASYSTEM-OVER 4 IEA) 200
builder will have the burden of proving that he did not build or i - . .
an- . BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 RES IND CON PB' Other
❑ 1,as owner of the property,am exclusively eo . .
ntracling with p' 1:1 . ❑ ❑ ❑.
licensed contractors to 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 an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts lot such projects with a contractons)licensed pursuant to SEWER-SAN V-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO, PARCEL NO.
❑ Iso exempt mtder Sec. ,B.&P.C.for Olis WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSA'IION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate of consent to self-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy Ihercof(Sec.3800,Lab.C)ZD .G lNtN/�
Policy No. Company ll�]
Q ❑ Certified copy is llereby furni.teal. FIRE SPRINK ENERGY T 24
z Z ❑ Certifi osy is flc '1 he city inspection division. MISC.- REFER TO ORD.
F O Applicant r Y [] N E] Y E] NC3
N' I CIiR PICA' :OIs F.XHMI'TION PRO RRI!RS• PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU 1 COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
1 O fl'his section need not.be completed if the permit is for one TOTAL Y❑ , NF] Y,E] N'[3
Z) 2 hundred dollars IS 100)or less I
U O 1 certily that in the performance of We work oor 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. -
y Dam Applicant - ALTER OR ADD TO MEC 5.00 BUILDING
} W NOTICE '1'0 APPLICANT: If,after making IN,Certificate of lix-
F ? emption,you should become subject to the Workers'Compensalion APPLIANCE O PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE I
5..0 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT IT F . 0
CONS'I'RUC'fION LENDING AGENCY AIR HANDLING UNIT IO 10000SEISMIC FEE ,
I hereby affirm GF.M.)that there is a construction lending agency for EXHAUST HOOD (WITH %10#0
the performance of the work for which this perrail is issued(Sec MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100, 0 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address E LECTR I C
Icatify that l lmve read this application and state that the a have VENTILATION FAN (SINGLE) 4.00 ,-
information is correct. I agree to comply with all city and county PLUMBING
ordinances and slate laws rotating to building constnretion, and BOILER-COMM 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 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', mets and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City na consequence of the U
gmn'�of this Pero' MECH.CONT. LIC.NO. MECH_44i
p( TOTAL TOTAL
Si not pplsant onttua Dam -
OFFICE COPY