09553 APPLICANT TO,FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
AODING APPLICATION & PERMIT 09553
ADDDRESS
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
O •/ PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
1..NCONTN
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
ic.No.CXLIGHTING FIXTURES 10.00/1.00
ADDRESSS APPLIANCES-RESIDENTIAL 4.00
f v ONE _ PANELS 10.00 DATE OF APPLICATION
ARCRI ECT PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMPI 20.00
ENGINEER
uc.NO. SIGNS TRANS. 3.00 s '
ARCH.OR ENG, PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00
ZIP EMP. METER OR POLE INS. 20.00
AMOTORS SEE FEE SCH. (PAID'
ADDDRESSDRESS
SERVICE CHANGE 20.00
neaas
o o LICENSFU CONTRACTORS DECLARATION TEMP.POLE 30.00 AUG 2 3
Q U o I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
N a w (commencing with Section 7000)of Division 3 of the Business and BL E T. �PL MECH,
D z Professions Cod end my license is in full force and eff t p
O i m W Licensc nes t Lic.Number ` _�� 0.UIT
Date se Contractor
a y f BUILDING PERMIT
at rc w o OWNER-BUILDER DFCLARA'PION INFORMATION
K:
3 LL I hereby affirm-that I am exempt from the Contractor's License MISC.- REFER�TO ORD
.. O¢ Law for the following reason.lSec.7031.5,Business and Professions pERMIT ISSUANCE 10.00 VALUATION S/FT.
Code-'.Any city or county which requires a permit to construct,alter,
_
Q Q ¢ IInluove,demolish,or repair any structure,prior lO Its Issuance,also ELEG CONTE. LIC.NO. ELEC.
O ¢ requires the applicant for such permit to file a signed statement that TOTAL P ED TT
a w es ac he is licensed pursuant to the provisions of the Contractor's License
z i Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r o the basis for the alleged exemption.Any violation ofSection 7031.$ STO IES TYPE CONSTR.
se B by any applicant for a permit subjects the applicant m a eivil,cmdly ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500)_):
Cl 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEV ICE 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 does not apply to an owner of
property who builds or improves thereon,and who docs such workFIXTURES-PER TRAP 5.00 00 so.FT.FLOOR AREA TOTAL ACREAGE
himself or through hemployees.provided own emploprovided that such improve_
meats are not intended or offered for sale,if,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 8.00 ��
or improvement is sold within one year of completion,the owner- 'GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 3000 E IND CON PB Omer
.
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ .❑
licensed contractors to construct time 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 property who'boilds or improves thereon.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts to,such projects withsa contractor(')licensed Pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 Op
the Contractor's License Law TRACT NO. PARCEL NO.
❑ lam exempt under Sec�,B.&P.C.for this WATER HEATER W/VENT 6.00 00
reason
Owner Dole WATER SYSTEM 5.00 -00 ACC.OATE ACE.FILE NO.
WORK ERS'C_OMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate of ecuRenl to self-insure, ZONING ENG SITE NO.
' or a certificate of Workers'Compensation Insurance,or it certified.
copy thereof(Sec.3500,Lab.C.).
Policy N . Company
O ❑ Certified copy is hereby fumished. FIRE SPRINK REENERGY T 24
Z Z �. Certified py is Eledr with the city inspection division.
FO Acplicant�{,Tr fy.r .., [ MISC.- REFER TO ORD. YE] NE] Y ❑ N❑
W CL'RTIPICArEOF EXEMPTION I7ROM WORKERS' PERMIT ISSUANCE 10.00 UO FLOOD ZONE A.L.U.C.
W > COMPI'NSATION INSURANCE PLG.CONTE. LIC.NO. PLG 00
CL 0 (This section need not be completed if be permit is for one TOTAL Y N� Y [:] NF]
hundred dollars IS 100)or less.)
U 0 1 certify that in lire performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued, 1 shall not employ any person in any manner so as to
O w become subject to tireWorkers'Coommiction Laws of California. BUILDING
y Dole Applicant ALTER OR ADD TO MECH. 5.00
} (D NOTICE TO APPLICANT. If,after making flux Certificate of Ex-
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
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10)000GF.M.) 4.00
CONSTR UCTION 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
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 Name H EATING UN IT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that l have read this application a nd slate that the above V ENTILATION FAN (SINGLE) 4.00
•
onto..nation is correct, I agree to comply with all city and county PLUMBING V�
ordinances and stale laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.1 6.00
hereby authorize representatives of this city to enter upon the gO1LER-COMP (Over t00,0008TU15EE FEE SCH. MECHANICAL
above-montioned property for inspection pmposcs.
(We) agree to save, indemnify and keep Imrmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
gmnti oft 'spemdL MECH.CONT. LIC.NO. MECH.
JUn t On ��a/ TOT"` TOTAL
Sigi7 to o ApF itant Con m ate ,
" INSPECTOR COPY