09540APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT I DENTI FICATI ON
APPLICATION &PERMIT
BUILDING - ELECTRICAL -PLUMBING -MECHANICAL
PERMIT NUMBER
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D J t.1
FUILDIN
BUILDING
1 Qr
Uvolurn'S
NAME LI 1S
PHONES )I -J`l �I
QTY: ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
NAME ALTO s
UTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1,00
TRAcTOR's
ADDRESS
PPLIANCES- RESIDENTIAL 4.00
PHONE
DATE OF APPLICATION
PANELS 10.00
Ancrairicl
oa
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE
PC No.
ENGINEER
LIC. No,
SIGNS TRANS. 3.00 -
ADDRESs END.SPECIAL
CIRCUIT 5.00
PERMIT VAL
EMP. METER OR POLE INS. 20.00
^ y N 3
AUGZIP
qp
IiJsS
APPLICANT $
OREs
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
City of Cupertino
LICENI Sl i DCON'IRACTORS DECLARATION
TEMP. POLE 30.00
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code and my license is in full force nd effe
License Class %-Lie. Numbe,2 06M__
ISSUANCE DATE
BLDG.
❑
ELECT.
❑
PLG. MECH.
EX E
Dot, - Comructor
BUILDING PERMIT
INFORMATION
OWNER -BUILDER DECLARATION
I hereby af-irm that I am exempt from the Contractor's License
Law forthe mlluwimin.,on.(Sec. 7031.5, Busln,ssand Professions
Cade: Any city or county which requires a permit to construct, alter,
MISC.- REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
$/FT.
ELEC. CONTR. LIC. NO.
ELEC.
TOTAL
improve, demolish, or repair any structure, prior 10 its issuance, also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to lire provisions of the Contractor's License
PERMIT TO
QTY, PLUMBING PERMIT FEE
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5
STO IE
TY CONSTR.
by any applicant for a permit subjects the applicant tox civil penalty
of not more than five hundred dollars ($500),):
ALTER -DRAIN & VENT -WATER (EA.) 5.00
❑ 1, as owner of the property, or my employees with wages a
their sole compensation, will do the work, and IIIc structure is not
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA,COND. 5,00
intended or offered for Sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law docs not apply V an owner of
FIXTURES - PER TRAP 5.00
GAS - EA, SYSTEM - I INC. 4 OUTLETS 6.00 c00
SO. IT. FLOOR AREA
TOTAL ACREAGE
property who builds or improves thereon, and who does such work
himself or through his own employees, provided the such improve-
mentsarenotintendedorofooed for sale. If, however, the building
or improvencenl is sold within one year of completion, tire owner-
builder will have (lie burden of proving that he did not build or int-
I'll -
prove for purpose ofsale.).INDUSTRIAL
❑ 1, as owner of the property. am exclusively contracting with
GAS- EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDING USE
E INO CON Pa Omer
❑ ❑ ❑ ❑
.
WASTE INTER30.00
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
licensed contractors to construct Ire project (Sec. 7044, Business
and Professions Code: The Contractor's' License Law does not apply
to an owner of property Who builds or improves thereon. and who
ASSESSORS PARCEL NO.
,
LAWN SPR INKLERS - OVER 5 (EA.) 1.00
contracts for such projects with a contrxetods) licertwd puomm:,Io
lite Contractors License Law.
SEWER -SANITARY -STORM EA. 200ft 10.00 UO
/
TRACT NO,
PARCEL NO.
❑ 1amexemptRuder Sce. ,B.&P.Cfor cis
ova%an
WATER HEATERW/VENT 6.00 6V
Owner Dat,
WATER SYSTEM 5,00 -O
ACC. DATE
ACC FILE NO.
WATER TREATING EQUIP, 5.00
WORK F-RS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of1mllent to seirm"uc,
ora certificate of Workers' Compensation Insurance, or a c,rlil'icd
ZONING
ENG. SITE NO.
kopy thereof (Sce. 3800, Lab.C.L
Policy No. Company
FIRE SPRINK
V N
❑ ❑
ENERGYT24
V N
❑ ❑
Certified yopy is Filed with tale city inspection division.
❑ Cerlifiedcopyishercbyfu..Maid, ,rr�G q
Appl cant-Ls
MISC.- ,REFER TO ORD.
CHR'DPICATE OF HXEMPI[ON 17ROM WORKERS'
PERMIT ISSUANCE 10.00
FLOODZONE
A.L.0 C.
COMPENSA'T'ION INSURANCE;
I IIII, section need not be completed if the permit is for one
Y ❑ N ❑
Y ❑ IN E]
PLO. CONTR. LIC. No.
PLG.
TOTAL W
hundred dollars IS 100) or I., I
I certify that in the performance of the work for which III, per-
mit is issued I shall not employ any person in any manner so as to
OTY. MECHANICAL PERMIT 'FEE
FEE SUMMARY
BUILDING
become subject to the Worker,' Compensation Laws of California.
Date Applicant
NOTICE. TO APPLICANT: If. after making this Certificate of Ex-
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00
PLAN CHECK
FEE
emption, you should become subject to the WorkL,, Com.,nsation
provisions of the Labor Code, you most forthwith comply with
such provisions or this permit shall be deemed revoked
AIR HANDLING UNIT (TO 10OW CF.M.) 4.00
AIRHANDLING UNIT(OVER I0,000C.F.M.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that Lucre is a construction lording agency for
EXHAUST HOOD (WITH DUCT) 5.00
the perforncnce of to work for which this permit is issued (Sec.
3097, Civ.CJ.
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address
HEATING UN IT (OVER 100,000 B.T.U.) 9.50
ELECTRIC
VENTI LATION FAN (SI NG LE) 4.00
I ... lify that l have read this application and stale that the above
mornclion is correct. I agree to comply with all city and county
ordinances and state laws relating to building construdimt, and
PLUMBING
00
gOILF37-COMP(3 H.P.or 100,0008.T.U.) 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to emcr upon Ile
above mentioned property for inspection purposes,
(We) agree to save, indemnify and keep harmless the City of
MISC. - REFER TO ORD.
Capertino against liabilities, judgments, costs and expenses which
a
clay in any s' conic met said City in consequence of the
CONST. TAX
PERMIT ISSUANCE 10.00
gran lgiy'�p1f [h' crmi, \//h/j
MECH. CONT. LIC. NO.
MECH.
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TOTAL
TOTAL
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INSPECTOR COPY