9395 (2) AP.,PLICANT 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
A DURESS
BUILDING -ELECTRICAL-PLUMBING -MECHANICAL 9395
A9MPPLAN CHECK VALIDATION
NAME '46-'14 IID- QTY. ELECTRIC PERMIT FEE
vHorvE
NA RA ; OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME
t LIC.NO. LIGHTING FIXTURES 10.00/1.00
ABBE
EESS Rs PPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 10.00 r DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP] 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER y
uc.No. SIGNS TRANS. 3.00
ADD ESS ENG.
SPECIAL CIRCUIT 5.00 PERM ION
ZIP TEMP.METER OR POLE INS. 20.00 JUL
a
AMOTORS SEE FEE SCH. G W 1981,'
ADDDRESSDRESS
SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 y City Of Cupertino
a i w I hereby affirm that 1 am licensed under provisions of Chapter 9 fir ISSUANCE DATE
Gay (commencing with Section 7000)of Division 3 of the Business andBLDG. ELECT. P G MECH.
Z H w i Professions Code,and my license is in full force and effect ❑ ❑ ❑\
License Class Lic.Number
t
Dam •Contractor
P
w
Y s BUILDING RMIT
¢ ¢ a OWNER-BUILDER DECLARATION
y 0 a O - INFORMATION
I hereby affirm that I am exempt from the Contractors License MISC.- REFER TO ORD
OR Law for the following reason, 7031.5,Rasinessand Professions PERMIT ISSUANCE 1000 VALUATION - $/FT.
Code:Any city or county which requires a permit lo construct,alter,
¢ aa a improve,demolish,or repair any structure•prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
d W m LL requires the applicant for such permit t0 file a signed Statement that TOTAL PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License
H z ¢
Law(Charter 9(Conimencing with Section 7000)of Division 3 of the
E O Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ H m the basis for the alleged exemption.Any violation of Section 7031.5 5 -_TYP1 CONSTR.
y3by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(S500T):
0 1,as owuer of the property,or my cm ployces with wages as BACK,F LOW PROTECT.DEV ICE 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,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 los such wurk FIXTURES-PER TRAP 5.00 SD.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees.provided that such improves
meats 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, the owner. GAS-EA.SYSTEM-OVER 4 IEA.] 2.00
buil c will have the burden of proving that he dill not build or im- BUILDING USE
e fur purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 E IND CON PS Other
I,as owner of the property,am exclusively contracting with Cl ❑ ❑ ❑
I d contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSE SSOHSPARCEL NO.
a rofessimS Code:"rhe 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 orsuch Projects with a Contraelobs)license(]pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
P-1 To under Sce. ,B.&P.C.for this WATER HEATER W/VENT 6.00
ason
)wncr Darn WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
W'ORKERS'CO.MPEN$AT'ION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure. ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
O 0 Certified copy is hereby furnished. FIRE$PgINK ENERGY T Y4
Z Z' 0 Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.O Applicant = Y ❑ N❑ Y ❑ N[_]~ w
LU - CHR T]FIQf IiN5OF EXEMPTIONFROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.c.
W � COA1PIATlON INSURANCE PLG.CONTR. LIC.No. PLG.
a- Z[ This section need not be completed if the permit is for one TOTAL YE] N❑ Y[:] NF]hundred dollars(S I ORU or Icss.l
U O 1 ceri]'y that in the performance o] the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I shall not employ any person in any manner so as to
0U-1 become subject to the Workers'Compensation Laws of California.
Date Applicant BUILDING
} W NOTIC17 TO APPLICANT: IL after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
f.. Z_ 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,O000.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 for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(See MICROFILM
3097,Cis CA HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is Inrrecl. I agree to comply with all city and County PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives 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 hannlese the City of MISC.- REFER TO ORD.
Cupertino against liabiliti s,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
ting of this per ,� MECH.CONT. LIC.NO. MECH.
S TOTAL TOTAL
Signa m o pp I<anl ontmc re Jam
INSPECTOR COPY
t3 I