09630 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT 1 DENTI FICATI ON PERMIT NUMBER
.UILDING APPLICATION & PERMIT O�n��
ADDRESS
}� BUILDING - ELECTRICAL-PLUMBING-MECHANICAL b
OWNER'S
NAME PLAN CHECK VALIDATION
_ QTY. ELECTRIC PERMIT FEE
PRONE!I O
NOMERgcroRs UTLETS-SWITCHES-RECEP 10.00/1.00
LIC,NO. .5'• LIGHTING FIXTURES 10.00/1.00
ADDRESS
oR's APPLIANCES-RESIDENTIAL 4.00
CONTRACTORS
l
"7 (' 7. _ a PtLONE PANELS 10.00 DATE OF APPLICATION
ARCHITECTV��_ �.L+-+pro.-•e.t (�i 9y, � PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
uc.No. SIGNS TRANS. 3.00
ARC"Ess ENG, SPECIAL CIRCUIT $,QQ PER TION
APPLICANTS
ZIP rrEMP.METER OR POLE INS. 20.00 `!5 MOTORS SEE FEE SCH. J�fry
4 ���5
ADDRESS /l
y __ J,�A,J SERVICE CHANGE 20.00
w o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 City of Cupertino
Fz w I hereby affirm that I am licensed under provisions of Chapter9 ISSUANCE DATE
G udi Imnvnrncing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. M C
H w z Professions Code,and my license is in full force and effect. ❑ ❑ ❑
Z O m - License Number 14
f /•
9 y H w Dafia�9- 2-2 i:; Contractor 'A »T/Z 141- d
m s 33 •9-9--Off BUILDING PERMIT
tt ¢ st OWN17 R-BUI LDER DECLARAI[ON
A o a o INFORMATION
wg LL _ I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u O j Law for the following reason.(Sec.7031.5,Business and Professions L VALUATION S/FT.
_ PERMIT ISSUANCE 10.00
� �� � Code:Any city or county which reyuiresa permit toconstrucLel0.•r,
le u, ¢O improve,demolish,or repair any structure,prior to its issuance,also ELEC. . LI
CONTRC.NE
0. LEC.
LL requires the applicant for Such permit to file a signed statement that TOTAL i
A w m he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
zaLaw(Chapter 9(commencing with Section 7000)ofDivision 3 ofthc
E i D Business and Professions Code)or that he is exempt therefrom and
I_�. the basis for the alleged exemption.Anv,4iolatiun of Section 7031.5 QTY. PLUMBING PERMIT FEE STORIES TYPE CONSTR.
a3 _ by any applicant fora permitsubjects the applicant toacivilpenalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).S500).]:
❑ 1,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 ProfessionsDRAINS-FLOOR,ROOF,AR EA,CON D. 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 6O.FT.FLOOR AREA TOTAL ACREAGE
• mentsB re through his own employers,provided that such improve.
or improvemenotnt tended Tor within
ronefor
year
If.mpleceq the the owner-
GAS-EA.SVSTEM-11 6.00
or improvement will
is sold within one year of completion, the owner-
builder will Hove tileburden of proving that he did not build or inI- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
prove fillof purpose ofe.). INDUSTRIAL WASTE INTER. 30.00 qEs IND cont ve Omer
❑ L th
as owner of the property, exclusively contracting with
licensed contractors to construct the
project(Sec. 7G44,does r Business LAWN SPRINKLER$-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
oma Professions Code:The Contractor's License Law does not apply
to tr owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt ander Sec. ,B.&V.C.for alis WATER HEATERW/VENT 6.00
reason i
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK F,RS'COM PENSA'TION DECLARATION WATER TREATING EQUIP, 5.00
I hereby affirm that I have a certificate of consent to self-insure.
or a certificate of Workers'Compenmtion Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.)-
Policy No.A1jy„p�Comp:my
O O' Ccrtlhed copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is filed with the city inspection division. MISC- REFER TO ORD.Q Applicant Y NE] Yi] NE]F
LUT- CE RTI IICATF.OP EXEMPTION FROM
WORK FLOOD ZONE A.L.U.C.
W > COMPIiNSATION INSURANCE
PERMIT ISSUANCE 10.00 CE PLG.CONTR. LIC.N0. PLG.
CL 0 (This section need not be completed if the permit is for one TOTAL Y E] NEI Y E] N
Z hundred dollars IS 100)or lem.l
U O 1 certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE
FEE SUMMARY
W F mit is issued,1 shall not employ operson in any manner so to
O become subject to the Workers'Cno onmenmtion Laws of California.s
U Lu Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>_ N NOTICE TO APPLICANT': If,after making this 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 forlhwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10SMC.F.M.) 4.00
. CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 n
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.CJ HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Nana i
Lender's Address � HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify tAel-tfav9,,adqh?sapplication and state that the above VENTILATION FAN (SINGLE) 4.00 p ��
• information is correct. I agree to comply with all city and county PLUMBING
ordinances and stale law,u relating m building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
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, indenmify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs unit expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against mid City in consequence of the .ir
gmntingofthis permit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
(gnat"L4:_f OP¢an[ antra r a e 131 O n
INSPECTOR COPY '