09534 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FI CATION _ PERMIT NUMBER
BUILDING APPLICATION & PERMIT oJ �
ADDRESS
W Gr Car - BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
rvE 5 ' _ PLAN CHECK VALIDATION
F-
NAME �11i- yet QTY. ELECTRIC PERMIT FEE
• PNONE V 'i / V/
NAMEAa(
AcraR UTLETS-SWITCHES-RECEP 10.00/1.00
uc.No. LIGHTING FIXTURES 10.00!1.00
, NrOAcroRs
ADDRESS PPLIANCES-RESIDENTIAL 4.00
ALPHONE - PANELS 10.00 GATE OF APPLICATION
A WEone E PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
' LIC.No. SIGNS TRANS. 3.00
ARCH.ESS ENG. SPECIAL CIRCUIT 5.00 P�pr.�T IOATION
ZIP EMP.METER OR POLE INS. 20.00 •1�_q�/Y�
APPLICANT s MOTORS SEE FEE SCH. AUG G 1JDJ
ADOREss JVVJ
SERVICE CHANGE 20.00
00 LICENSED CONTRACTORS DECLARATION I TEMP.POLE 30.00 City of Cupertino
¢ u I hereby affirm Ihat I an, licensed under provisions of Chapter 9 ISSUANCE DATE
wn (commencing with Section 7000)of Division 3 ofthe Business and
¢ BLDG. ELECT. PL MECH.
H m i Professions Code,and in,license is in full to," ad of e
z o w - License Chs - Lia.NunlherdL .a
9 w- O Dam Contractor
am E BUILDING EMIT
Gia, i OWNER-BUILDER R-BUILDCIt DECLARATION INFORMATION
w3..g u N I hereby at IPut Ihat I am exempt from the Contractors License MISC.- REFER TO ORD
¢o4 -Law for the following reason.(Sec.7031.5.Businessand ProfessionsPEflM1T ISSUANCE 10.00 VALUATION $/FT.
Code:Any city or county which naluira o permit to construct,alter,
2 ¢ Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
co O u requires the applicant for such permit to file a signed statement(hat TOTAL PER IT TO
La m
a he is licensed pursuant to the provisions of the Contractor's License
F z < Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe /'
E O Business and Professions Code)or than he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ Hplite basis far lite alleged exemption.Any violation of Seclion703L15 STO Ty CONSTAR..
byanyapplicam for a permit subjects the applicant ton civil penalty ALTER-DRAIN St VENT-WATER IEA.) 5.00
m
Of not more than five hundred dollars(5500)):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUPRES.UNITS
their sole compensation,will do the work.and the xtRacmPc 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 improvesthereon,and who does such work FIXTURES-PER TRAP 5.00 00 SOFT.FLOORAREA TOTAL ACREAGE
• himself or through his own employees,provided that such imProve-
ments are not intended or offered for sale.If.however,the building GAS-EA.SYSTEM-11 NC.40UTL ETI 6.00 GQ
or improvement is sod within one year of completion,lite owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or ire- BUILDING USE
prove for purpose ofsale.). RES IND CON PB OlberINDUSTRIAL WASTE INTER. 30.00 El 0 El 1:1❑ I,as owner ol'the property,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contruc(or's License Law does not apply
to an owner of property who builds or improves(hereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contmctur(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 GO
thn CDnlraclor's License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec, ,BAP.C.for this WATER HEATER W/VENT 6.00 r(.Q
reason
Owner Date WATER SYSTEM 5.00 00 ACC.DATE ACC.FILE NO.
WORK IiRS'COMPFNSA'I ION DI:CI.ARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have u cer(ilic:de of consent to sell'-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sac.3500,Lid,C.).
Policy No. Company
O ❑ Certified Copy is hereby furnished. FIRE SPRINK ENERGY T 24
z Z Certified ePpy II, filed with the city inspection division.
O Appl em2.r.. 6..'a �3 MISC.- REFER TO ORD. y � N� v ❑ N�
CC .
CCrn- PERMIT ISSUANCE 1000 CIiRTII'ICATIi OF EXIiM PTI FROM WORKERS' On FLOOD ZONE A.L.u.C.
W > COSIPI!NSAITON INSURANCE PLG.CONTE. LIC.NO. PLG. oa y❑ N❑ V NE]z (This section nacA no( be completed if the permit is far one TOTAL
hundred dollars($100)or less I
V O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued.I shall not employ any person in any manner so as to
become subject to(he Workers'Compensation Laws of California.
do Date Applicant BUILDING
} N
NOTICE 'I'O APPLICANT: If,after making this Cer(ifica(e of Gx- ALTER OR ADD TO MECH. 5.00
(_ ? 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=QF.NL) 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10MC.EM.) 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 HEATI NG UN IT 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that 1 have read this application and state that the above VENTILATION'FAN (SINGLE) 4.00 vo
• information is correct. I agree to comply with all city and county PLUMBING
crdinmtees and state laws relating to building construction, and BOILER-COMPI3 H.P.or 100,000 B.T.U.) 6.00
hereby authuniv represculatives.of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino -pairs, liabilities,judgutents, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
Play in any wary accrue against said City in consequence of the
gruntin of s permit. MECH.CONT. LIC.N0. MECH.
YO EHL TOTAL
S t Ap ¢ant ontrantar at -
INSPECTOR COPY