9443 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LD1 NG PROJECT I DENTI FICATION PERMIT NUMBER
\." BOILOING APPLICATION & PERMIT
/• a 9443
7Y �'A SRC+PlLYo4 _ ' n, ry'r BUILDING -ELECTRICAL-PLUMBING -MECHANICAL
OWNEB'S - PLAN CHECK VALIDATION
NAME
�i0 a ELECTRIC PERMIT - FEE
F6TO '
PNONE
Y' t� CONTRACTOR'S ysS�i
NamE �T. UTLETS-SWITCHES•RECEP 10.00/1,00
-o 4;w .TSE 4&*niv4Llc No. LIGHTING FIXTURES 10.0011.00
co
AO NTRacTOR'sc,2/ruts
PPLIANCES-RESIDENTIAL 4.00
��xs-�
1�
DRESS (/(Q PHONE 9o1'•s�9.SJ' PANELS 10.00 DATE OF APPLICATION
ARCHITECTOR __FLAN(OVER 200 AMP) 20.00 Q PLAN_CHECK FEE P.C.NO.
ENGINEER
LIC.NO SIGNS TRANS. 3,00
ADDDDRESS ENa SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP ITEMP.METER OR POLE INS. 20.00
ADDRESS MOTORS SEE FEE SCH. Q cJ- _ - � �
ADDRESS a /\.`�WA�/
SERVICE CHANGET 20.00
PA
ND LICENSED CONTRACTORS DECLARATION TEMP.POLE ND 30.008/�/ef +
a v w I hereby affirm that I am licensed under provisions of Chapter 9 UANCE DATE
P,< (commencing with Section 7000)of Division 3 of the Business and oBLDG. ELECT. PLG. MECH.
r w Z Professions Code,�jt�r8y license is in full ford I V
o i w D -License Class Con Number ractor
w�
Date Contractor '
¢ o w OWNER-BUILDER DFCLARA'fION �� Cupertino BUILDING PERMIT'
iz g a.a. I- I hereby affirm that 1 am exempt liom the Contractor's License MISC.- REFER TO ORD INFORMATION
'o .. o¢ Law for the following reason.(Sec.7031.5,Business Professions O VALUATION $/FT.
H -,A PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
QQ Q 0O improve,demolish,or repair any Structure,prior IU Its issuance,also ELEC.CONTR. LIC.NO. $LEC. rr}r.��''
D LL requires the applicant for such permit to file a signed Statement that TOTAL Ila PERMIT TO
a w m m he is licensed pursuant to the provisions of Ore Contractor's License EL Ems/
HZ >
Law(Chapter 9(commencingwith Section 7000)ofDivision 3 ofthe
g i o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE,
to H $ the basis for file alleged exemption.Any violation of Section 7031.5STORIES TYPE CONSTR.
a3 � by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars($5007.):
CI 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,GOND. 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 re through his own employees.Provided leve such improve-building
,1 hiarts mself a throuot gh
his or employees,ffered for provided
thals the building GAS-EA.SVSTEM-11NC.40UTLETS 6.00
(( or improvement is sold within ane year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
RES IND CON PB Orbar
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00
❑ d as owner of the property,amt exclusively contracting with ❑ ❑ 0 ❑ 0
licensed contractors In construct the project(Sec. 7044,ofBusinessply LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts
couacts for such projects with a contmnor(s)licensed pursuant to SEWER-SAN ITARV-STORM EA.200ft/10.00
Nle Contractor's License Law. TRACT NO. PARCEL NO.
❑ I am 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'COMPENSAT10N DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent mself-ins Ire.
or a certificate of Workers'Compensation Insurance,In a certified ZONING ENG.SITE NO.
'copy thereof(Sc. Op�..ys{-1
Policy No ( Ed l}511P
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T24
Z, ❑ Ce copy_i til the y inspection division.
AppliNe
canrt�+ I00LA MISC.- REFER TO ORD. Y[:] NE] I Y [] No
� T CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
ION
CL , (This section need not becompletedRif t e permit is for one CII PLG.CONTR. LIC.NO.
FOG
CL TOTAL Y N Y ❑ N
o
::) Z hundred dollars($100)or less.)
U 0 1 certify that in the performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY'
IL I. mil is issued,I shall not employ any person in any manner so as to
O w become subject to the Workers'Compensation Laws of California.
Q. Date - Applicam BUILDING
>_ W NOTICE TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
Z emptiom you Should become Subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of Ihe.Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10.000GRM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT 100,000 B.T.U.)9.50 /1 W
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information n correct I agree to comply with all city and county PLUMBING
ordinances and stove laws relating to building all
anion, andmy BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP IGYBr 100,000 BTU)SEE FEE$CH. 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
acc
may in any way rue against said City in consequence of the
' granting of til is pe it.MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signature of Applicant/C tactor Date
OFFICE COPY