C9402 -g!zapy I'
• APPLICANT TOFILLIN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON .PERMIT NUMBER
anLOING APPLICATION & PERMIT
ADDRESS 9402
;LoBUILDING -ELECTRICAL-PLUMBING-MECHANfCAL
Ow ER"B PLAN CHECK VALIDATION
NAME RV '/� I CITY. ELECTRIC PERMIT FEE 77 yG
NAme ACTORS UTLETS-SWITCHES-RECEP 10.00/1,00I
/�/S7�
V/ / LAO, LIGHTING FIXTURES 10.00/1.00 , w
CONTRACTOR 5 APPLIANCES-RESIDENTIAL 4.0071
DRE55 AO6 'PHONE PANELS 10.00DATE OF APPLICATION
ARCHITECTPLAN CHECK FEE P,C,NO.
OR SA',r✓ cOSE PANELS (OVER 200•AMP) 20.00
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDDDRESS ENG, SPECIAL CIRCUIT 5.00 PERMIT VAL1�T� ,
ZIP EMP. METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH. AUG
�79ee�
ADDRESS
SERVICE CHANGE 20.00 AUM
O o LICENSED CONTRACTORS DECLARA'r10N TEMP.POLE 30.00 City of Cupertino
'Q uI hereby affirm that 1 am licensed under provisions of Chapter 9 ISSU NCE DATE
w (commenc
y a ing with Section 7000)of Division 3 of the Business and I•a a ELF PLC. MECH.
F w z I'mfnsiuns Code,incl my license is in full Tome and effect. r
z: 0 m - LIcC,,,C Claus 8
DLic.Numticr wqw �4
O H Data CORDan
- x BUI DING PERMIT
wOWNER-BUILDER DECLARATION INFORMATION
w3 n y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u 004 I.aw for the followingreason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
F _J Code:Anycity orcounly which requires a permit loconslruel,alter, ^Oj�
IF al c O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC. U v
LL requires the applicant for such permit to file a signed statement that TOTA PERMIT TO
A w m m he is licensed pursuant to the provisions of the Contractor's License
Hz >
Law(Chapter 9(commencingwilh Section 7000.I'Division 3ofthe
4 Business and Professions Code)or that he is exempt therefrom andQTY. PLUMBING PERMIT FEE
F c lire basis for file alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
05-: by any applicant for a permit subjects the applicant toe civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars($500).): -
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCG GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Seo. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CON D. 5.00
Code:'I'hc Contractor's License Law docs not apply to an owner of
property who builds or Improves thereon,and who does such work FIXTURES-PER TRAP 5.00 60.FL FLOOR AREA TOTAL ACREAGE
h ullell'or through his own em DloYecs,provided that such""prove-
mm�ls are not intended or offered for sal,.If,howcvcr,the building GAS EA.SYSTEM-11 NC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or in,- BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 I❑ ❑N EPB -ouvel4
❑ 1,as owner of the property,am exclusively contracting with 11
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 contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
file Contractors License Law. TRACT NO. PARCEL NO.
❑ I and exempt under Sec.-,B.&PC.for tills WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have accrtilicalu of consent toself-insure, ZONING
or a eerlifcale of Workers'Compensation Insurance,or a cer ificd ENG.SITE NO.
cup,thereof(Sea 3800,Lab.C.).
Policy Nn. Company
O ❑ Certified copy'is R,Rhyfuruhed. FIRESPRINK ENERGY T 24
Z Zcertified copy is filed with the City inspection division.
~
O fi,a,I MISC.- REFER TO ORD. YEj NN[] Y ❑ NE]
PERMIT ISSUANCE 10.00
� v- CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ZONE A.LU.C.
LL > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. v N Y C] NE]
CL D 1'I'his section need not be completed if the permit is for one TOTAL
hundred dollars IS 100)or less.)
U O I certify that in tare performance of the work for which this per- OTV MECHANICAL PERMIT FEE FEE SUMMARY
LL I- Out is issued, I shall not employ any person in any manner so as to
❑ become subject to the Workers'Compensation Laws of California.
U a Data Applicant i ALTER OR ADD TO MECH. 5.00 BUILDING
} W NO RCE '1'0 APPLICANT. If,after making this Certificate of fix- -'
�!2 etnption,you should become subject to the Workers'ConlPcnsatim, I APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, yoN,mawilh SI t0uhcomply with
U such provisions or this permit shall be deemed revoked, AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0)000OFM.) 6.00 SEISMIC FEE /
I herehy affirm that there is a construction ImWingageney for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097.Cie.C.).' -- // HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name A4A1/0' HEATING UNIT l00,000B.T.U.)9.50
Lender's"Addo, ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• information is correct.1 agree to comply with all city and county - PLUMBING
ordinances and state laws relating to building construction. and BOILER-COMP 13 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000BTU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmles.e the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in W y way accrue against said City in c0loNcenee of the PERMIT ISSUANCE 10.00
granlin• 1'this jronni . MECH.CONT. LIC.NO. MECH. '
TOTAL TOTAL !
t r pficam/ moor D'u c
- INSPECTOR COPY
a`