11567 (3) ,"APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
(I+;frtCPERMIT NUMBER
p%nw BUILDING PROJECT IDENTIFICATI APPLICATION & PERMIT'
ADOPO� I \ {•J\
J �ESS
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S : . . PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE•
CONTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
E `f
LIC.No. LIGHTING FIXTURES 10,00/1.00
,. roNTRACTmrs PPLIANCES-RESIDENTIAL 4.00
AOOPE55^} / p
'- Y• U. /• PHONF p �' , I PANELS 10.00 DATE OF APPLICATION
''-•r"" AARRCITECT PANELS IOVEfl 200 AMP) 20.00 PLANCHECK FEE P.0 NO.
ENGINEER'
LIc,No, SIGNS TRANS. 3.00
ARCH.OR END. SPECIAL CIRCUIT 5.00 PERM _�gry'ION
L ADDRESS
EMP.METER OR POLE INS. 20.00 yy
APPLICANTS MOTORS SEE FEE SCH. JUL y a
ADDRESS �•YL•J
SERVICE CHANGE 20.00
O o O LICENSED CONTRACTORS OrCLARATION City of Cupertino
aU I hereby affirm that l am licensed under provisions of Chapter 9 ISSUANCE DATE
N le y (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r G u Professions Code aqd I y license is in full fore•and effect.
' 0. - License C ma-a. LIc.thumb• ❑ ❑ ❑ ❑
O Z H O Date -a'-b-Commute �. C
i
a se ¢ a OWNER-BUILDER DLCLA'1tA 1/O LFLZ'ed :-in.`:,BUILDING PERMIT,',,;m�ti.y
a c w u REFER TO ORD "t• >' INFORMATIONSE ,':'t:•'<'
W3 LL n 1 hereby affirm that I am exempt from the Contractor's License MISC.- VALUATION S/FT.
ILO q Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00
' ~ y,0• - Code:Any city or county which requiresa permit taconstruct,alter,
•Q u, ¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
Lic O u requires the applicant for such permit to file a signed scaler cut that TOTAL PEHMIT TO
A x$ he is licensed parstmnt to the provisions of 0u•Contractor's License m
=iaLaw(Chapter 9(commencingwith Section 7000)uf Divisiun3 office r
4 O Business and Professions Code)or that he is exempt therefrom and DTV '; n i PLUMBING PERMIT FEE
IS the basis for the alleged exemption.Any viul,ition of Section 7031.5 .+ STORIES TYPE CONSTR.
i 3 - by any applicant for a permit subjects the applicant to a Civil penalty ALTE -DRAT ENT- ATE EA.) 5.00
of not more than five hundred dollars($500t):
❑ 1,as owner of the property,or my employees with wagesas BACK FLOW PROTECT. DEVICE 4,00 OCC.GROUP HES.UNITS
their sole compensation,will do the work,and the structure is not - -"
intended or offered ]of 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 wilt)builds or Illlproves there ill,and who does such work FIXTURES-PER TRAP 5.00 50.FT.FLODfl APEA TDULACREAGE
'•`. himself or through his own employees,provided that such improve. -EA.SYSTEM-11NC.4OUTLETS 6.00
-
mentsuremintundeduralteredlorsalt.11,however,the building GAS
ore
r impravennlrnt is sold within one year of conpgetion,the owner-
builder will have the burden of proving that he did nut build or int GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove lot purpose of sale.). INDUSTRIALWASTE INTER. 30.00 RES WD CON PB Om.,
❑ I,as owner of 01e property,wt)exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors Ill construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code: flu,Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.I 1.00
contracts for such projcels with a contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM V-STORM EA.200tt110.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.Ian Nis WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK BRS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have n certiticate of consent to sell-insure. ZONING ENG.SITE N0,
or a certificate of Workers'C.open"
Run In n,c,or ace Rilwd
COPY Nerco,3(Sec�.3-800-J1p�')',A •
PulicY NO. GTAfs�,.'i/Idi,1d- Olt t}_r1Qe0-a+,J]s%
0 ❑ Cerlikedcopyishere66y_furnished. FIRE SPRINK ENERGY T24
Ce it a y is,f 'd with tic city ins on Division.
Zp p an��,yJ�� [zpsu(T.4G1_a,-p. 4Ny`�';`''� MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
I - `) d._.L-.1 :1 PERMIT ISSUANCE 10.00 0 FLOOD ZONE A.L.U.C.
I'PICAI{i OP 1iXhMl'Il(yN P120 WUI<KIiNS'
LU COMPENSATION INSURANCE LG.CCNIR G 0 PLG, '�T Y❑ N 0 Y ❑ NO
d O (This section mrd not he completed if lila permit is Inn on �E// N TZ,L1 TOTAL `;
2 hundred dollars($100)or less.) -rte -
U 0 1 certify that in the performance of the work for which Ibis per- OTY. MECHANICAL PERMIT, ' FEE' FEE SUMMARY
LL F- mit is issued, I shall not empluy any Person in any manner w,as Ia Y
O become subject to the Workers'Compensation Laws.1 Cabe ria.
0 y Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} m NOTICE 'TO APPLICANT': If,cher making Nis Certificate of F.-
Z emPtion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
(� such provisions or this pennit shall be deemed revoked, AIR HANDLING UNIT ITO 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE
I hereby afl'irnl that there is a construction lending agency for EXHAUST HOOD (WITH DUCTI 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C). 1y . HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name-il-� HEATI NO UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
Lender's NAddrame /IiCJ
1 certify that I have read this application and state that the above I V ENTI LATION FAN (SINGLE) 4.00
• information is correct.I agree to comply with all city and county BOILER•COMPl3 H.P.Or 100,0008.T.U.) 6.00 PLUMBING
` ordinances and sate laws rdaing to building consrucloc anJ
hereby authorize representatives of this city to enter upon the BOI LER-COMP (Over 100,000 BTU)SEE FEE SCH, MECHANICAL
above-mentioned property'to
mchion Purpoxs.
(We) agree ho sane, i "roof, nd keep harnlcss the City of MISC.• REFER TO ORD.
Caper' u against liabi"les,judge •nts, Costs' anJ expenses which CONST.TAX
zzzany way ace a ugai said City in C.nugl ace o the PERMIT ISSUANCE 10.00
1 this perm . �C Xy/ MECH.CONT. LIC.NO. MECH.
I ' L cL'['. !c/ Y 1 -1/ MECH. TOTAL
Signature of A cant C'onractar Vale
OFFICE COPY