9441 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
• BU LDI NG PROJECT 1 DENTI FICATI ON PERMIT NUMBER
RDILDING APPLICATION & PERMIT
ADDRESS
joxz�
/
BUILING-ELECTRICAL-PLUMBING-MECHANICAL 944
OWNER'
PLAN CHECK VALIDATION
�[ NAME / QTY. ELECTRIC PERMIT FEE
• SUN G ONE
NAMERACTOR UTLETS-SWITCHES-RECEP 10.00/1.00
LiC.No. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR S APPLIANCES
4.00
A DORESs
PHONE PANELS 10.00 PATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO, SIGNS TRANS. 3.00
ADDRESS ENG. - SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP fTEMP.METER OR POLE INS. 20.00
AMOTORS SEE FEE SCH.ADDRESS
ss ,\
SERVICE CHANGE 20.00
0 LICENSED CONT RACTORS DECLARATION TEMP.POLE 30.00
<u u 1 hereby affirm that 1 am licensed under provisions on-Chapter 9 ISSUANCE DATE
m Z "' Icommencin with Section 70001 of Division 3 of the Business and a u g BLDG. ELECT. PLG. MECH.
F i Professions Code,and my license is in full force and effect. ❑ ❑ ❑ `
o0�.O License Class Lie.Number-
0 Z
ac
Date Coatmemr
a Y E BUILDING PERMIT
Q
w g OWNER-BUILDER DECLARATION
INFORMATIONa o a
H 1 hereby allium that 1 am exempt front the Contractor's License MISC.- REFER TO ORD
u o st Law for the following reason.(Sec.7031.5.Businessand Professions VALUATION $/FT.
_ PERMIT ISSUANCE 10.00
Code:Any city or county which requirese permit toconstruct,,ab,
p improve,demolish,or repair any permit
toff prior to its issuance,also ELEC.CONTR. UG NO. ELEC.
a wDLL requires the applicant for such permLL 10(dc a signed Statement that TOTAL PERMIT TO
m he is licensed pursuant to the provisions of the Contractor's License ^
Hzi Law(Chapter 9(commencing with Section 7000)of Division 3 of the L
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
f o
M H p the basis for the alleged exemption,Any violation of Section 7031.5 STORIES TYPE CONSTR.
a ; r' by any applicant for 11 permit subjects life applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred Jollars(S5001.1'.
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensalion,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 does not apply to an owner of ^
property'who builds or Improves thereon,and who does such work FIXTURES-PER TRAP 5.00 I' SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such Improve.
ments are not intended or offered for sale.It.however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, the owner GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or int RES IND CON PB Omar
prove for purpose of suleJ' INDUSTRIAL W ASTE INTER. 30.00
❑ L as owner of the property,am
exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contmctons)licensed pursuant to SEWER-SAN V-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec,-,B.&P.C.for this WATER HEATER W/VENT 6.00
real.,
Owner Date WATER SYSTEM 5.00
T -Gly
ACC.DATE ACC.FILE NO.
W'ORKIiRs'COMpENsn'1'[ON DISCI-nitnTloN WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a cCITIFIc3le of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is filed with the city inspection divizion. MISC.- REFER TO ORD.
O Applicant Y❑ N❑ Y ❑ IN
N CERTIFICA'fli OP EXI MPTION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
L � COAIPL'NSATION INSURANCE PLG.CONTR. LIC.NO. PLG
CIL . V❑ N❑ V ❑ N❑
0 This section need not be Completed if the permit is for one TOTAL
D Z hundred dollars($100)or be
L) O 1 certify that in life performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F, mit is issued,I shall not employ any person in any manner so as to
Q 0 become subject to the Workers'Compensation Laws of California.
O_ Dam Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
Co NOTICE 'rO APPLICANT: 11,after nwkm,this Certificate n1Fs-
F ? em piton,you should become subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK
provisions of ire Labor Code, you must lorthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT ITO 10MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.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.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's bLuRc
o
AddHEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's
I certify that have read this application and slam that the above VENTILATION FAN (SINGLE) 4.00
• information is correct.1 agree to comply with all city and county -COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction. and BOILER
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
granum .fit penni6 MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
,/'L=tYVDI APPIVELIRUE.11M.Clirur- Da
INSPECTOR COPY
t 1