9038 (2) '%APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PR6JECT I DENTIFICAAft IF *10 PERMIT NUMBER
Sun-DING APPLICATION & PET
/A S � BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 9038 '_
WNE '9
PLAN CHECK VALIDATION
Al"
QTY. ELECTRIC PERMIT FEE
ofqlkPHONE
CONTRACTORR'_S,, UTLETS-SWITCHES-RECEP 10.00/1.00
NA (JVIV C LIC.N ILIGHTING FIXTURES 10.00/1.00 '
woo TRACTORS PPLIANCES-RESIDENTIAL 4.00
a be uirl PHONE IPANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200'AMP) 20,00 PLAN CHECK FEE P.C.NO.
OF
ENGINEER
LIC.No. ISIGNS TRANS. 3.00 -
ADDRRassENO' SPECIALCIRCUIT 5,00 ��dlTll�'QLIDATION
ZIP TEMP.METER OR POLE INS. 20.00
ADDRESS MOTORS SEE FEE SCH. .MAY
SERVICE CHANGE 20.00
w o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 City, Of CUpArtl66
< I hereby affirm that I am licensed under provisions of Chapter 9
F Z: i ISSUANCE DATE
(commencing with Section 70001 of Division 3 of the Business and SLOG. ELECT. PLG. MECH.
r S" Professions Codc nd icense is in full for ffegt.'L ❑ ❑ ❑
Z 0 u�'i^ License Class Lie.Number
4 w Ow Dale C67 ontractor-__tlQ
IS aa -OWNER-BUILDER DECLARATION BUILDINQ PERMIT
iL INFORMATION
I hereby affirm that I am exempt from the Contractor's License IMISC. REFER TO ORD VALUATION S/FT.
H_O Law for the following reason.(Sec.7031.5,Businesf dnd Professions
g PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
rt rt 40 0 improve,demolish,nr repair any sticture,prior n i[s issuance,Ilan ELEC.GDNTfl, LIC.NO. ELEC.
w0 u requires the applicant for such permit to file a signed statement that TOTAL R T TO
m he is licensed pursuant to the provisions of the Contractor's License
LiQ Law(Chapter 9(commencingwilh Section 7000)ofDivision 3 ofthe
3 z 0 Business and Professions Code)or that he is exempt therefrom and
I- the basis for the alleged exemption.Any violation of Section 703 LOTV. PLUMBING PERMIT FEE
5 STORIES TYPE dONSTR.
by any applicant for a permitsubjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(4500).):
❑ 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
Properly who builds or improves thereon,and w111...such work F IXTURES-PER TRAP 5.00 SO,FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
meets-are not intended or ffered for sale.If,however,the building GAS-EA.SVSTEM-11NC.40UTLETS 8.00
Or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 ES IND CON PB Omer
. .
❑ 1,as owner of the property,am exclusively contracting with D ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,BusineuLAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSOPS 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 for such projects with a contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
C, 1..exempt under Sec..,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM - 5.00
ACC.GATE ACC.FILE N0.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I I hereby affirm that I have a certificate of consent to self-insure,
/pzV/I or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C,).
Pal' o. Company
Q rttred cop reb�famishe FIRE SPRINK ENERGY T-24
ZfZ ❑ C rlified - f d ith m ci y 'nspe do 'v"
F O Applica t MISC.- REFER TO ORD. Y [] N[3 Y ❑ NE]
W CERTIFICATE OF EXFMPTION FR WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.G.
IL W COMPENSATION INSUR NCE PLG.CONTR. LIC.NO. PLG, ❑ ❑ ❑ EJ
(This section need not be completed if the permit is for one TOTAL Y N Y N
hundred dollars IS 100)or leu.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,1 shall not employ any person in any manner so as to
Q W become subject to the Workers'Compensation Laws of California.
0. Date Applicant ALTER OR ADD TO MECH. 500 BUILDING
>_ N NOTICE TO APPLICANT: If,after making this Certificate of Ex- .
Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Cade, you'musl forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO lo=r-F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10MC.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.C.). � HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
1 certify that 1 have read this application and stale that the above 3 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 2BOILER-COMP 13 H.P.or 100,000 B.T.U.) 6.00
hereby'authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000STU)SEE FEESCW MECHANICAL
above-mentioned property for inspection purposes.
(We),agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino Short liabil"es,judgments, costs and exp se which PERMIT ISSUANCE 10.00 CONST.TAX
may i a way ace e a said City in corse enc of Ih ,
g f Ii per f/ MECH.CONT. LIC.NO. MECH.
Iry OV 'o'A(v^f-/2l/J'1' � TOTAL
/�f gnature of Applicant/Contra or Date .
/ OFFICE COPY