9208 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATION
PERMIT NUMBER
BUILDING APPLICATION & PERMIT
�( Ao�o-R1Ess _
/ �(5 F1 F_ sTA U4nJ BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 9208
OWNER'S PLAN CHECK VALIDATION
-_ ( NAME
0l_ l µ1 QTY. ELECTRIC PERMIT FEE
ON • IL 11�slcl' PHDNEA s-zb6
rvAMERAcroRs OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.No. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR
ADDRESS PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECTPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO,
ENGINEER
Llc.No. SIGNS TRANS. 3.00
moo Eoss ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP- EMP. METER OR POLE INS. 20.00
APPLICANT rs MOTORS SEE FEE SCH. S
ADDRESS
SERVICE CHANGE 20.00 -71
0 0 o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a o u 1 he,ehy affirm tlmt I am licensed under provisions of Chapter 9 ISSUANCE DATE
Nz w (commencing with Section 7000)of Division 3 of the Business and
< BLDG. ELECT. PLG. MECH.
r m i Professions Code,and my license is in full force and effect. ❑ [:]T,
Elo 0 w o License Class Lic.Number - Invi
DateContractor
a Yf BUILDING PERMIT
ao ar U OWNER-BUILDER DECLARATION INFORMATION
w0 w y I hereby affirm that 1 am exempt Dom the Contractor's License MISC.- REFER TO ORD
.. o et LSw for the following reason.(Sec.7031,5,Bo,inessend Professions PERMIT ISSUANCE . 10.00 VALUATION $/FT.
I � > E Code:Any city orcouity which requires o permit to construct,alter,
IS a, Q O improve,demolish,or repair any structure,prior to Its issuance,also ELEC.CONTR. LIC.NO. ELEC.
ca
rc requires the applicant for such permit to file a signed statement that TOTAL
w w he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
HZQ LBw(Chapter 9(commencing with Section 7000)ofUivision3oftire Y Mr`s v
E i o
Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
r o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR:
A. by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five Imndred dollars($5000f):
❑ I,as owner of the property,or nay employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCG GROUP RES.UNITS
their wlc compensation,will do the work,and the structure is not
intended or offered for sale(Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractor's License Law does nal apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 s0.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve.
mems are not intended or offered for sale if,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
or improvement is wild within one year of completion,the owner- GAS EASYSTEM-OVER 4 (EA) 200
builder will have the burden of proving that he did not build or im - . . .
- BUILDING USE
prove for purpose of sola.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB One,
13I,as owner ol'tire property.am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 g55EBSOR$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 IEA.) 1.00
contracts for such projects with a contractor(s)liuunscl pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. I TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-.BAP.0 for this WATER HEATER W/VENT 6.00
reason
Owner - Date r WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO,
WORKERS'COMP: ATION DEC &RATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to sel Ginsurc. ZONING
or a certificate of Workers'Compensation Insurance,or a certificd ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z ❑ Certified copy is file) with the city inspection division.
C Applicant MISC.- REFER TO ORD.
O Y ❑ N❑ v ❑ N❑
cc: y CER'rlFICA I E01'EXEM PTION PROM WORKERS, PERMIT ISSUANCE 10.00 -FLOOD ZONE A.L.U.C.
LU > COMPF,NSA'I'1ONINSURANCE PLG.CONTR. LIC.NO. PLG, Y❑ NE] V❑ N❑
Z (This xcctihin need not lie conhpleted if ilia penult is for unc TOTAL
hundred dollars IS 100)orless.I
U'O 1 certify that in the performance of the work for which this per- TV. MECHANICAL PERMIT FEE FEE SUMMARY
UL F mit is issued,I shall not employ any person in any manner so as to
O w become subject to(lie Workers'Compensation Laws it California.
W [)are Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} w NOTICI: 1'0 APPLICANT': If,after nwking this Certificate o1Ex-
Z enhption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 FEE x�
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10)D000F.M.) 6.00 SEISMICFEE
I hereby-affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the MICROFILM
)performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lenders Name HEATING UNIT(OVER 100,000 B.T.U.)Lender's Address ELECTRIC
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, andBOILER-COME(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over&00,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, Indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMITISSUANCE 10.00 1111, CONST.TAX
may in any way accrue again said City in consequence of the
granlinpppof this pen tiL ///��L••• �T MECH.CONT. LIC.NO. MECH. r
TOTAL J TOTAL
\/Jl/ Sigat c u n[Contructous' �- v [)are/ L
INSPECTOR COPY