09622 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LOI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
UILDIN
ADDRESS APPLICATION & PERMIT o
W
7,9 /! Ac i BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
9 622
ONER'S lit -CYh-�--ws" PLAN CHECK VALIDATION
NAME /! QTY. ELECTRIC PERMIT FEE
vRorvE - /
NOMERAcroRs OUTLETS-SWITCHES-RECEP 10.00/1.00
iq Q(T CLIC.ND. t LIGHTING FIXTURES 10.00/1.00
CN
ACDSS ons
ADREAPPLIANCES-RESIDENTIAL 4.00
IIA-3 v ONE k, J PANELS 10.00 DATE OF APPLICATION
ARCRITECT aA PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
Llc,No. SIGNS TRANS. 3.00 ^,
coo Ess ENG. SPECIAL CIRCUIT 5.00 PERMIT N
ZIP EMP.METER OR POLE INS. 20.00
APPLICANT s MOTORS SEE FEE SCH. y SEP 4 1985
%sf.a L Y,,_,�-�,���.r.c-Lly,(% SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 City of Cupertino
a v 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
H o n (commencing with Section 7000)of Division 3 of the Business and
¢ BLDG. ELECT. PLG. C
Z F m i Professions Cocke.and my license is in full force and effect. ❑ ❑ ❑
O to - License ClaSY^ .-�4-=/-Lie Number.�t >/� S
o - w Datee-*G.4aa-o- cal -Contractor 4A:5tZ �+v./� ''
a y f _:.3 q �q B BUILDING PERMIT
¢ ¢ OWNERB UILDFR DECLARATION
a 2 u,- INFORMATION
w ;LL _ I hereby affirm that I am exempt from the Contractor's License MISC-- REFER TO ORD VALUATION
FU04 Law for the following reason(Sec.703 L5,Business Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
¢ w ELEC.CONTR. LIC.NO.
¢ ¢ o improve,demolish.or repair any structure,prior to its issuance,also ELEC.
D IS requires the applicant for such permit to file a signed statement that TOTAL ERMIT TO
a w m m he is licensed pursuant to the provisions of[tie Contractor's License
a, > Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
¢ Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
¢ o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPIFCOINSTR.
per _ by any applicant for a permit subjects the applicant Ina civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than Five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACK F LOW 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,AR EA,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 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
ments are riot intended or offered for sale.If.however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
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 DR. BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 ES IND CON PB Omer
❑ I,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 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 SEWER-SANITARY STORM EA.2001[/10.00
the Contractors License Law. r TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,BAP.C.for1his WATER HEATER W/VENT . 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACE.FILE NO,
WORKfiRS'COMPF.NSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofconsenl to self-insure- ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sec.3800,Lab.0)�.x,, Q
Policy�No/��Ap�-Company Lr[ ^`^"'
Q p Ceti,Cd�op`y is hereby fum¢hed' FIRE SPRINK ENERGY T 24
Z 2 ❑ Certified copy is filed with the city inspection division.
O Applicant MISC.- REFERTOORD. Y ❑ N❑ Y ❑ IN
CC y CE RTI F I CATE OP EXEMPTION PROM WOR K FRS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W 7 COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PILO
Z (This action need not be completed if the permit is for one TOTAL Y❑ N Y ❑ N❑
hundred dollars IS 100)or less.)
U O I certify that in tire performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued.I shall not employ any person in any nhanner sit as to
O becomes object to lire Norkers'Compensution Laws of Culifomia.
0 W DiRe Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} 0 NOTICE TO APPLICANT: If,after making this Certificate of Ex-
(- 2 cmption.you should become subject to the Workers'Conmeasation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must lorthevith comply with FEE
U inch provisions or this permit shall be deemed revoked. AIR HANDLING UNIT ITO 10,030C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
1 hereby gffirsc that mere ism 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-�-�-
Lendersnddress ' n f"f.i ,L/�L� (� 0i HEATI NG ON IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I gtfly4t�5t 1l9f t'cud9h a�p(d on and state that the above VENTILATION FAN (SINGLE) 4.00 �n
information is correct.I agree to comply with all city and comity PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMPO H.P.or 100,000 B.T.U.) 6.00
hereby autlmrtic representatives of this city w enter upon the BOILER-COMP IOvm 100,000 BTUI SEE FEE SCH. MECHANICAL
above-nwctioned property for inspection purposes.
(Wc) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
clay in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00 11600
grantin•of this permit. MECH.CONT. LIC.NO. MECH.
- TOTAL 2.566, TOTAL
Igna ate of ApplicentiContractor Is- - 13u@
INSPECTOR COPY