C9414 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATION PERMIT NUMBER '
sWLDING �. APPLICATION & PERMIT
ADDRESS /7 /Q��p[
V/ / BUILDING -ELECTRICAL-PLUMBING-MECHANICAL VT 4,
OWNER'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
. t//V�(/(,YF LJIPMDNEI lV //VV
ONTRACTORS
NAMEUTLEL_SWITCHES-RECEP 10.00/1.00
_ J / /I
LIG
S � LIC.N YQ`I HTING FIXTURES 10.00/1.00
CONTRACTORS
ADD ��./A&V �/[ APPLIANCES-RESIDENTIAL 4.00
RESS / A
S r.I PHOry 3 ;I/S7 PANELS 10.66 DATE OF APPLICATION
RCHIr ECT �yr7 Nry PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
O ,
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH.
ENG' SPECIAL CIRCUIT 5.00 PERFyKglygaTION
SS
IIP EMP. METER OR POLE INS. 20.00 1 PT'A�Id APPLICANT MOTORS SEE FEE SCH. �1V4 196
ADDRESS A
SERVICE CHANGE 20.00
o o I.ICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 City of Cupertino
a v u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y¢ a (commencing with Section 7000)of Division 3 of the Business and B ELECT. PLG. MECH.
r w z Professions Cq,' Ipd n y icensc is m full for e' tiff I.
z O m- ,License Class` '1 Lie.Number �-
Q m Uale !-
Contractor-YQF�jrfa�L
y E BUILDING PERMIT
IS w u, OWNER-BUILDER DECLARATION INFORMATION
w 3I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TOOL
u . VALUATION $/FT
W .
F u_ o J Law for the following reason.(Sec 703 1.5,Business and ProfessionsPERMIT ISSUANCE 10.00 t.
Code:Any city or'county which requires a permit to construct,alter, !
Q ¢ Q p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
- O G requires the applicant for sucllii permit to file a signed statement that - TOTAL
w ,� he is licensed pursuant n the provisions of the Contractor's License PE MIT TO
rzr
Law(ChapterPruoosione(commencingwithSection is 00)exempt
Dtherefion oofthe
a Business and he alleged
Code)or that he is exempt therefrom and QTV. PLUMBING PERMIT FEE
KFo the basisfor plilire allegedexemption.Any applicant
Of Section703L$ STORIES VPE CONSTR.
a3E'
by any more than
for apunrt subjects the 00.): ant hsacivil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more tllan five hundred dollars(SS00).):
❑ 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 docs not apply to an owner of
property who builds or improves thereon,and who docs such work F IXTURES-PER TRAP 5.00 SO.FT FLOOR AREA TOTAL ACREAGE
himself"or through his own employees,provided that such improve-
mentsarenotintendedorofferedforsale,If,however,the building GAS-EA,SYSTEM-111NC.40UTLETS 6.00
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 air- GAS USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND PB Other
❑' 1,as owner of me properly,an exclusively contracting with ❑ ❑ ( ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSO RCEL NO.
and Professions Code:The Contractor's License Lew 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 contracmr(s)licensed pursuant m
the Contractor's License LawSEWER-SANITARY-STORM EA.200ft/10-00 TRACT NO. PARCEL NO.
.
❑ l in,exempt under Sec ,B.&P.C.for the, WATER HEATER W/VENT 6.00
reusmt
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DPCLARAT ION WATER TREATING EQUIP. 5.00
1 hemby affirm that I have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a cer i¢ le f Workers'Compe ilio I uu ranee,or a cerci"
copy th O 0,Lab.CJ,
Policy o unman
y
-' Q illcd IC yfur c FIRE SPR INK ENERGY T 24
❑ Cer IIred ed t division. MISC.- REFER TO ORD.
Z
O Applicant V ❑ N❑ YE] N❑
ir N _FRTIF AT OF IH iMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOOZONE A.L.U.C.
W MPENS TION INSURANCE! PLG.CONTE. LIC.NO. PLG.
- This section need not he completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
Z hundred dollars IS 100)or less,
U O 1 certify that in the performance of the work for whichthis per- CITY MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued, I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California
DO Date-Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} m NOTIC17 1'0 APPLICANT. If,after making this Certificate of l-x-
Z emption,you sbould become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10JJOOC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
3097,the performance
ce of the work for which this permit is issued(Sec. MICROFILM
HEATING UNIT(TO 100,000 B.T-U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T-U.)9.50
Lender's Name ELECTRIC
I certify that I have read this application and Slate that lire above VENTILATION FAN (SINGLE) 4.00
information is corme[. I agree to comply with all city and County PLUMBING
oruinonces and state laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,0008.T.U.) 6.00
hereby authorize represettlalfecs of this city to enter upon lire BOILER-COMP IOvar 100,000 BTU)SEE FEE SCH. MECHANICAL
above mentioned properly for inspection purposes.
(We) agree to save, indemnify and keep harmless lire City of MISC.- REFER TO ORD. I
Cupertino a 'ns[ liabiliti judgmems, coals and expenses which CONST.TAX
may in a wa ecru gainst S Cily n consequent o the PERMIT ISSUANCE 10.00 _
grand this miL i MECH.CONT. LIC.NO" MECH.;
OTAL TOTAL
Signa re of Applic [/Conlmctor. Dale
INSPECTOR COPY
y