C9421APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -*USE BALL POINT PEN ONCV-
BUI LDI NG PROJECT 1 DENTI F[CATION
APPLICATION & PERMIT��
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
F
BUILDING
ADOREss
OwNE 'S
PLANC CK VALIDATION
NAME
OTY. ELECTRIC PERMIT FEE
HONE
rRACToas
NAME \
Llc. No. '�
OUTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
ADDRESS T 's {
PPLIANCES-RESIDENTIAL 4.00
PANELS 10.00
P
DATE OF APPLICATION
RCn
R
PANELS (OVER 200 AMP) 20,00 .1
PLAN CHECK FEE P.C. NO.
NGINEER
uc. No.
SIGNS TRANS. 3.00
ADDRESS BNc'
SPECIAL CIRCUIT 5,OQ
PERMIT VALIDATION
211
TEMP. METER OR POLE INS. 20.00
tw.�
AUG , It
�,
City OISSUANCE.OATE
APPLICANT '$
ADDRESS
MOTORS SEE FEE SCH,
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Ch.plc, 9
TEMP. POLE 30.00
(commencing with Section 7000) of Divis1. 3 of the Business and
Professions Co Bnd my license is in full To 'c un effect.
License Class"- { Lic. Numbe/
BLDG.
❑
ELECT:
❑
I IIPLG. MECH.
❑ -. ❑
Date_-�__ �j� Contra
BUILDING PERMIT
INFORMATION
OWNER -BUILDER DE:CLARA'f10N
I hereby affirm firm I an, exempt from the Contractor's License
Law for [fie following reason.(See 7iTesu Business ttocodProfessions
Code:Any city Dr countywhiny requires, Toch nstn¢t,alter,
MISC.- REFER TO ORD
PERMIT ISSUANCE 10.00
-
VALUATION
SIFT.
-
ELEC. CONTR. LIG. NO.
ELEC. (/J
TOTAL �' ��-
prior
improve Amnolish, or repair any structure, prior to its issuance, xso
requires lire applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9(commencing with Section 7000)of Division 3 ofthe
Business and Professions Code) or that he is exempt therefrom and
/W/ v i U
PERMIT TO
/N % 'e 0'� EMO
QTY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for apem,it subjects the applicant to a civil pcmlty
art ot n,om than five Ilundred dollars (8500).1: 1
❑ I, as owner of The property, or my employees with wages a$
their sole compensation, will do the work, and the structure is not
ALTER -DRAIN -WATER (EA.) 5.00
BACK F LOW PROTECT. DEV ICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA,COND. 5.00
intended or offered for sale (Sec 7044, Business and Professions
Code: The Contractor's License Law docs not apply to an owner of
properly who builds or improves thereon, and who does such work
himself' or through his own employees, provided that such improve-
reentsare not intended orofferedfor sale If. however, the building
FIXTURES - PER TRAP 5.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
or improvement R sold within one year of completion, Ore tireowner-
-
builder will have ,e burden of proving that he did not build or in,--
prove for purpose of sale.).
❑ 1, as owner of the property, am exclusively' contracting with
. ..
GAS EASYSTEM -OVER 4 (EA) 200
BUILDING USE
RES IND CON PB O,he,
Q ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct the project (Sec. 7044, Business
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 -,1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
r
contracts for such projects with a contr,eturts) licensed pursuant In
the Comraclnr's License Law.
SEWER -SANITARY -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
❑ I am exempt under Sec.-. B.&P.C. for this
WATER HEATER W/VENT ,6.00
reason
Owner Date
WATER SYSTEM 5.00
ACCDATE
ACC. FILE NO.
WORKE-RS'COMPENSATION DECLARATION
WATER TREATING EQUIP. 5.00
of consent or
I hereby affirm that I have a ce Compensation eiti ed
or a cert I'icate of 3800, i Compensation Insurance, or a certit icd
OR
,copy then flSec. 3800, Lab.C�,
_ ZONING
_�
ENG. SITE NO.
No. Com
FIRE SPRINK
Y ❑ N ❑
ENERGY T 24
Y ❑ N❑
❑ Certified copy is hereby 1 m6 t.
❑ Certified copy is filed with the city inspection Aivisioa
APP[ICan t_A� [h�T=nc-i--1`""e. a44�
CER' IWIICATEOIC' I YEM`PT'•OONN FFRROM WOR_R IS{R S'
MISC.- REFER TO ORD.
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.UD.
COhIPENSATION' INSURANCE
IT section need not be completed it the permit is for one
PLG. CONTH. LIC. NO.
PLG.
TOTAL
Y ❑ N ❑
Y ❑ N❑
hundred dollars (S 1001 or Icss.)
1 certify (bar in the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner so as to
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
b,,o ne subject to The Workers' Campcnsallnn Laws of California.
Dmc Applicant
NOTICE '1'0 APPLICANT: If, after making this Certificate of ISx-
LTER OR ADD TO MECH. 5.00
APPLIANCE 5.00
PLAN CHECK
FEE
�7
s-�Z
emption, yon should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT (TO 10=CF.M.) 4.00
AIR HANDLING UNIT (OVER 10000.EM.) 6.00
SEISMIC FEE
CONS'fRUCI[ON LENDING AGENCY
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 fSec.
3097, Civ.C.).
c1t-si.-
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address
HEATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
I certify that l have read this application,nd state that fit, above
VENTILATION FAN(SINGLE) 4.00
information is correct. I agree to comply with all city and county
ordinances and stale laws relating to building cunslruction, and
me
hereby an oIme' fepracnlalives of this city to enter upon The
above%vie red properly I'or inspection purposes.
PLUMBING
BOILER-COMP(3 H.P. or 100,000 B.T.U.) 6.00
BOILER-COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
a
VV �G
x-
MISC. - REFER TO ORD.
pVe) age to save, indemnify and keep harmless the City of
Cupertino ag; liabilities, judgments, costs and expenses which
may in any ay accrue against said City in consequence of tire
CONST. TAX
PERMIT ISSUANCE 10.00 dl-
granfi dthis ermit.
e
ECH. CONT. LIC. NO.
MECH.
TOTAL 30
TOTAL
d53
Sgna re pplican Contractor Dale
INSPECTOR COPY