9158 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDINGAPPLICATION & PERMIT
A �� ��
ADDRESS
J OS-97 1A N BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
DANIEL S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
PHONE
name c Rs -37 UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S
ADDRESS APPLIANCES-RESIDENTIAL 4.00
�/ 11
y � - PHONE L� PANELS 10.00 DATE OF APPLICATION M.
/
ARCHITECT PANELS (OVER 200 AMP) X20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. X3.00
ADDRESS END. SPECIAL CIRCUIT 5.00 AuOnnoN
ZIP rEMP.METER OR POLE INS. 20.00 p q O
APPLICANT'$ MOTORS SEE FEE SCH. JUN 2 O I9o5
ADDRESS
SERVICE CHANGE 20.00 City Of Cupertino
02 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a u IHR I hereby affirm That I am licensed under provisions of Chapter 9 ISSUANCE DATE
m "' 1(conumenein,with Section 7000)of Division 3 of the Business and
¢ 6 BLDG. E ECT PL I MECH.
0 m m LicenProfese Cls Code.and my license is in full force and effect. ❑
0 o m - License Class Lin.Number 2&1S174 ..
o Z a
Date Contractor
R, Y f y BUILDING 9 RMIT
IS o SE atn U OWNER-BUILDER DECLARATION INFORMATION
X
g LL y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION $/FT.
Hu04 Law for the followingreason.(Sec.703 1.5,Businessand Professions PERMIT SSUANCE 10.00
Code:Any city orcounty which requires a permit to construct.alter.
¢ a, ¢ improve,Bunmlivh,or repair any structure,prior to its issuunce,also ELEC.CONTR. LIC.NO. ELEC.
la
O IS requires the applicant for such permit to file a signed statenKnt Ilam TOTAL / PERM T
A w m he is licensed pursuant to the provisions of tlm Contractor's License ky,
H z i Law(Chapter 9(commencing with Section 7000)of Divisiun 3 of the /
¢ Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
S, r the basis for the alleged exemption.Any violation of Seclion 7031.5 iTYPE CONSTR.
� 3 $ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5,00
of.of
fnot more than live hundred dollars(S500).): /
C1 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00 OCC.GRO P R 5.UrvlT3
their sole compensation,will do tire work.and the structure 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 improves thereon,and who docs 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 not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,tire owner- GAS-EASYSTEM OVER 4 (EA.) 200
builder will have the burden of proving that he did not huild or ice . - . .
. BUILDING USE
Prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES TND CON PB Gore,
❑ 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 ASSESSORSPARCELNO.
and Professions Code:The Contractor's License Law does Iwo apply
to an owner of property who builds or improves then ni.and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts forsuch projects with a eontraetorfs)licensed pursuant to 1
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sea ,B.&RC.for this WATER HEATER W/VENT 6.00
reit n
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO,
WORK Ii RS'COM PENSA f ION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofcoment tosel Gins"re, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a ce riffled
copy thcmnf(Sec.3800,Lub.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z led copy is fpt 'th the city inspection division. MISC.- REFER TO ORD.plicunl h Y❑ N❑ Y ❑ N❑
~ w r PERMIT ISSUANCE 10.00
'fI FICA IEX{A}YfIB�PROM1t WORKERS' FLOOD ZONE A.L.U.C.
LU CO PENSAI'ION INSURANCE PLG.CONTR. LIC.NO. PLG.
d6. ❑ N❑ Y ❑ NE]O (This section need ooPbe completed if the permlo.ia for one TOTAL V
Z) Z hlmdreddolla¢(SI000orlevs.)
L) O 1 certify that in the purl'urmencc of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as tO
Ow become subject to thie WorkerCompensation Laws of California. BUILDING
a Date Apphcanl ALTER OR ADD TO MECH. 5.00
} N NOTICE 'PO APPLICAN I': If al4x making this Ccroil'icam of 1:,,
FZ emption,you should become subject to[lie\Yorkers Compensal ion APPLIANCE 5.00 PLAN CHECK
provisions of the labor Code, you must forthm'll comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,(10DC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that There is a construction lending agency lox 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 Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address E LECTR I C
I certify that I have read this application and state that the above V ENTILATION FAN (SINGLE) 4.0
information is correct. I agree to comply with ul1 cloy and county PLUMBING
ordinances add state laws relating to building construelion, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.0
hereby autlwrme representatives of this city 10enter 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 liar nlcss the City of MISC.- REFER TO ORD,
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 70.00 CONST.TAX
may in any way accrue a sI said City in consequence of the
granting of this pen MECH.CONT. LIC.NO. MECH.
\�I / TOTA TOTAL
\ ignature fA cant/Contractor Date
INSPECTOR COPY ,