8369 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
,I BU I LDING PROJECT I DENTIFICATIO PERMIT NUMBER
BUILDING s APPLICATION & PERMIO ����
%DRESS '
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME - QTV. ELECTRIC PERMIT FEE
carve
CONTRActoRs
NAME TLETS-SWITCHES-RECEP 10.00/1.00 (pa-
f
'{ "C.No. GHTING FIXTURES 10.00/1.00 �•
C NTRACTORs - PPLIANCES-RESIDENTIAL 4.00
N AooREss
X ONE ANELS 10,00 DATE OF APPLICATION
RL ECt PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO,
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARC H.OR ENG. PERMITyVAtI TION
ADDRESS SPECIALCIRCUIT 5.00 n's+xy
APPLICANT$
Do, EMP.METER OR POLE INS. 20.00 AUG 9
ADDRESS - MOTORS SEE FEE SCH. 1 J 9 �J(fn^�
Y -
ER VICECHANGE 20.00 oU
0 a Z
` Foo LICENSED CONTRACTORS DECLARATIONatuaEMP.POLE 30.00 city of Cupertino
v U I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
v, a H (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT, PLG. MECH.
H D z Professions Code,and my license is in full force and effect.
z O_/,1 License Class IAc.Number
-
2 Z FIw Date , Contractor!q,
BUILDING PERI
IS,m w u OWNF-R-BUILDER DECLARATION - INFORMATION
'. w ;LL H I hereby affirm that I am exempt from the Contractor's License IMISC.- REFER TO ORD
VALUATION S/FT.
F LL O a Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00 /0
Code:Any city or county which requiresa permit to construct,of ISL
IS Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. /
K 0 LL requires the applicant for such permit to file a signed statement that TOTA PERMIT TO
p A w m he is licensed pursuant to the provisions of the Contractor's License i�
HiQ
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
4 D Business and Professions Code)or that he is exempt therefrom and QTV. PLUMBING PERMIT FEE J
re H o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
La
by any applicant for a permit subjects the applicant too Civil penalty f ALTER-DRAIN -WATER IEA.) 5[00
of not more than five hundred dollars(5500).):
❑ I,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: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 _S.00 SM FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees.Provided that such improve-
ments are not infended oroffered for sale.If.however,the budding GAS-EA.SYSTEM-1 INC.4 OUTLETS 6: J&_64j
or improvement Is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4(EA.) 2.00; BUILDING USE
prove for purpose of sale.). R 5 IND CON PB Other
❑ I,as owner of the,property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCE L NO.
and Professions Code:The Contractor's License Law does not apply j
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 couraetods)licensed pursuant to SEWER-SANITAR V-STORM EA.200ft/10.00
the Cont'actor's License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec. .B.&P.C.fur cis WATER HEATER W/VENT 6.00
•. reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC,FILE NO.
x
WORK IERS'COMPENSA'FION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent s sum' ZONING
or a Certificate of Workers'Compensation Insumnca,o cert
r a certified "ENG SITE NO.
Copy thereof f5ec.3800,/ LaV Policy No.-Company mpanyny
❑ Certified copy is hereby famished,wit - -; FIRE SPRINK ENERGY L]4
z Z ll. Certified copy is fled with the city inspection division.
'71 MISC.- REFER TO ORD0�_ '
Q APP Cunl � Y❑ No V ❑ N❑
F rn PERMIT ISSUANCE 10.0FLooD zoNE AL.u.c.
CC CIERTIFI r 'li. 0'N PROM WORKERS'LU > COMPENSATION INSURANCE PLG.CONTR. ❑c.NO. x PLG.d (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
r 2 hundred dollars(SI00)or les.) It
F U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U' mit is issued,I shall not employ any person in any manner so as to
r Qu become subject to the Workers'Compensation Laws of California.
a Date Applicant • LTER OR ADD TO MECH. 5.00 BUILDING
s } 2 NOTICE- TO APPLICANT: If after making this Certificate of lix-
F _ emption,you should become subject to the Workers'Compensation O�LI A NCE 5.00 PLAN CHECK
provisions of the Labor Code, you must for 1, ith comply wish
V such provisions or this permit shall be deemed revoked. HANDLING UNIT(TO 10.000 C.F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE ' a 03
,1 1 hereby affim, that there is a construction lending agency for EJHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this pcniut is issued(Sec.'30gTING UNIT (TO 100,000 B.T.U.) 8.00 ' µ MICROFILM
Lender's Name EAT!N G UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certify flat I 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
p ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 IRA
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-nientioned property for inspection Vur,o is. vV
- (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Caperfirm against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00 w` .
granting of this permi. r MECR CONT. LIC,NO.
L% I TOTAL
Signature o7 ppli .n n actor de -
INSPECTOR COPY