9494 I APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY.
BUILDING PROJECT IDENTIFICATION
PERMIT NUMBER
BUILGING APPLICATION & PERMIT 9494
x ADDRESS
OZ 7 O cn) IPE"ST CT BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME >SS-099 QTY. ELECTRIC PERMIT FEE
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vd oNE „-C/n �
NOMfRA ons OUTLETS-SWITCHES-RECEP 10.00/1.00
UC.ND. LIGHTING FIXTURES 10.00/1.00
°rona
ADDRES5 r- PPLIANCES-RESIDENTIAL 4.00
ODRE5
PHONE PANELS 10,00 1 DATE OF APPLICATION
ARCHITECT - PLAN CHECK FEE P.C.NO,
OR PANELS (OVER 200 AMP) 20.00
E NGINEEn
' uc.No. SIGNS TRANS. 3.00 PA
ADDRRESS eNc. SPECIAL CIRCUIT 5,00 PERMI N
ZIP EMP. METER OR POLE INS. 20.00 AUG 2 4
ADDRESS MOTORS. SEE FEE SCH. ��`-'�
ADDRESS
SERVICE CHANGE 20.00
w w o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 .City of Cupertino
< u w I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
N a c (commencing with Section 7000)of Division 3 of the Business and - BLDG. ELEC PL MECH.
H at
o z P,ofeselmts Code,and my license tr
e is in full uce and effect ❑
o Z w W License Clasx Lie.Number
Date Contractor
Ha y s BUIL IMG PERM IT
¢ o M sk U OWNER-BUILDER DECLARATION INFORMATION
w u; ¢ I- I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
o¢ Law for the following reason.(Sec.7031.5,Businessand Professions VALUATION
N 4 PERMIT ISSUANCE 10.00 d1,.
Code:Any city or County which requires a permit to constnmt,alteq
¢ ¢ Q 2 improve,demolish,or repair any Structure,prior to its issuance,also ELEC.CONTR. LIC.NQ ELEC, ti�
o ¢ requires the applicant for such permit to file a signed statement that TOTAL
n w m y he is licensed pursuant to the provisions of the Contractors License ( PERMIT TO
Larva Law(Chapter 9(commencing with Section 7000)ofDrosion 3 of the
E i o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE J
It F $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
1 6 ' f of not more than five hundreds dollar,(S500ects(lie Uaant toaCivil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00 '
04 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 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:Thi 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-
ounall ,c not intended or offered for sale.ll',however,the budding GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
1 or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or it GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
prove for purpose of sale). INDUSTRIAL WASTE INTER. 30.00 E IND C❑ON Pe Other a•.
I,as owner of the property,am exclusively contracting with
1 4 lied contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:"fine Contractor's License Law does not apply ,
- t to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
tcontracts for such projects with a contractods)licensed pursuant to
i; the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO, PARCEL NO.
❑n1 am exempt under Sec. lel agB.&P.C.let this
reWgTER(HEATER W/VENT 6.00
Owner Date �� WATER SYSTEM 5.00
ACC.DATE .ACC.FILE NO.
WORK S'
:RCOMPENSATION DECLARATION / WATER TREATING EQUIP, 5.00
1 hereby affirm that I have a certificme of consent to sell'-insure, -�� - ZONING ENG.SITE N0.
ora Certilicate of Workers'Compensation Insurance,or a certified'
copy tFrereof(Sce.3800,Lab.C.).
Policy`No. Company i
0 ❑ Certified copy is hereby furnished / FIRE SPRINK ENERGY T24
Z Z ❑ Certified copy is fled with the city inspection division. ;. MISC.- REFER TO ORD.
0 Applio:mt Y[] N[D YE] NE.
fY `� CERTIFICATE 01'EXEMPTION FROM WORKERS' t PERMIT ISSUANCE 1000/() FLOOD ZONE A.L.U.C.
W COMPENSATION INSURANCE PLO.CONTR. LIC.NO. PLG, (Fq Y� NEI Y � IN
Z (This Section need not be complete)etedif the permit is for one TOTAL
hundred
cert dollars IS 100)pe less.)
U O I certify that h the tc crudity
an of the work for which this pct- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
0 0 mit is issued,I shall not enmloy any person in any manner as to
Q w Doitc subject m the Workers Compensation Laws of California.o
a Date Appbc°m ALTER OR ADD TO MECH. 5.00 BUILDING SU
} 0 NOTICE.'1'0 APPLICANT': IL after nuking this Certificate of E.-
F 2 emptimt,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK e
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=C.F.M.) 4.00
CONS'I'RUC'I'ION 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(Sec. MICROFILM i
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 .f
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lenders Address ELECTRIC
I certify that I have read this application and state then the above VENTILATION FAN (SINGLE) 4.00
•
information n correct 1 agree to comply with all city and county BOILER-COMP13 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building cunzUud ion, and
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 harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
gmntingofthis permit. MECH,CONT. LIC.NO,
TOTAL TOTAL
ign r pp tee t Contract r Dat /
INSPECTOR COPY ,