09811 (2) :ANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDE TI FICATION APPLICATION & PERMIT , PERMIT NUMBER
Ate;#E"s ` 09811
- 7C7nn J JLDING-ELECTRICAL-PLUMBING -MECHANICAL
/ OWNERS , PLAN CHECK VALIDATION
NAME
s QTY. ELECTRIC PERMIT, . FEE
n N p rl
CONTRACTORS 3 UTLETS-SWITCHES-RECEP 10.00/1.00 •00
r`+I`ro 7#6 3 7 a LIGHTING FIXTURES 10.00/1.00 .0
�'- � LID.ND.
CONTRADDRR
croR's APPLIANCES-RESIDENTIAL 4.00
A7 %s A7 , L. F✓e NONE ' PANELS 10.00 ,f7 DATE OF APPLICATION
CHITECT
OR PANELS (OVER 200 AMP) 20,00 Z&g)6 PLAN CHECK FEE P.C.NO.
ENGINEER ..
LIC.140. SIGNS TRANS. 3.00
ARC H.OR ENG' SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDRESZIP EMP.METER OR POLE INS. 20.00
ADDRESrvr6 Ve �n VG • MOTORS 5 SEE FEE SCR. /'5,00
ADDRESS `Irk
Suys� B 0 J SERVICE CHANGE 20.00 ' pp
0 0 o LICENSED CONTRACTORS DECLARATION TEMP.POLE PAID 30A.0^0
a u I hereby affirm that I am IicenseJ under provisions of Chapter 9 D Fwo ar�O e"1�.0 ISSUANCE DATE
r-z¢ w (commencing with Section 7000)of Division 3 of the Business and
w y - r• PeT
�• r� BLDG. ELECT. PLG. MECH.
r H z Professions Cole,nn I m license is in lull force hn�d cf e ^ / /'-tin$ ('<nP e. J ❑ ❑ ❑
oi m License Class- _ I.ic.Number I
r m H aa Data Contractor Z i e o
City of Cupertino BUILDING PERMIT
S c0 u U OWNER-BUILDER DECLARATION INFORMATION '
X ; u _ I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
.. O¢ Law for the following reason.(Sec.703'1.5,Businessund Professions VALUATION S/FT.
_ J PERMIT ISSUANCE 10.00
0 /p, O
mCode:Any city or county which requires a permit to construct.
ELEC.CONTE. LIC.IN
Ie a ¢o improve,demolish,or repair any structure,prior to its issuance,also 17Q f ELEC.
a
DLL requires tum applicant for such permit to file a signed statement that v r TOTAL/�,QO PERMIT TO
w$ he is licensed 9(comst to the provisions o tire 700Co nlrnctoi s License C�
H i i Law(Chapter 9(co soon,Code)or Section is exempt
theron 3 of the G
¢ Business(or
Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
I i o
ILH the bustsfor the alleged exemption,subje.Any applicant
o to action 703L$ STORIES TYPE CONSTR.
5_: by by any applicant fore permit subjects lheapplicam toucivil penalty ALTER-DRAIN -WATER (EA.) 5,00
of not more than five hundred dollars(8500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 '
Cade:The Contractor's License Law docs not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 50,FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that suchint prove.
m
_ mes are not intended or offered for sale.if,however,flebuilding GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,lite owner GAS EASYSTEM OVER 4(EA) 200
builder will have the harden of proving than he did not build or inu. - . - . .
BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omar
❑ 1,as owner of the property,am exclusively contracting with 1:1 El 0 1:1 ❑
licensed contractors to construct the project(Sec. 7044, Business LAWN SPRINKLERS-I 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
commas for such projects with a contmaor(sl licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the tracts or such
License Low. TRACT NO. PARCEL N0.
❑ 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.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have acertiflaate ofconsent mself-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy(hereof(Sec.3800,Lab,C.). ,
Policy No. Compony�l�
Q q, Certified copy is horehy furnished FIRE SPRINK ENERGY T-24
'z 2 A _Cc
rtified�c�o�p,�a�fu Jed will a cit xsspec dvision.
Q Applicant-�s--s`'f- .xlD L /'hq n�• MISC.- REFER TO ORD. Y E] N Y ❑ N�
F rn PERMIT ISSUANCE 10,00
LU - CERTIFICATE F Ii TION ION FROM WORKERS' FLOOD ZONE A.L.U.C.
CL COd not Arno INSURANCE PLG.CONTR. LIC.NO. PLG. YE] N0 Y� N0
1 (This section need not be completed if the permit is for one TOTAL
L=) Z hundred dollars(5100)or less)
) 0 1 certify that in the performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LIE I. mit is issued,1 shall not employ any person in any nmnner so as to
O w become subject to the Workers'Compensation Laws of California.
Uatc Applicant BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
F Z 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 provisionsor this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE
1 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 Nome H EATI NG UNIT(OVER 100,000 B.T.U.)9.50 0
Leader's Address ELECTRIC d
I certify that I have read this application and state that the above h VENTILATION FAN (SINGLE) 4.00
information n correct I agree to comply with all city and county PLUMBING
ordinances formatio and state laws relating m building construction,co and ty BOILER:COW 13 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter'upon the 601 LER-COMP(Over 100,000 BTU)SEE FEE SCH.
above-mentioned property for inspection Purposes. / MECHANICAL
(We) agree to save, indemnify and keep harmless the City or ' MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way'accrue against s'' Ci in consequence of the
an ' gof this permit. MECH.CONT. LIC.NO. MECH.
10 TOTAL TOTAL
S' atureo Applicant/Contractor Uat
OFFICE COPY
I