11841r
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING •APPLICATION & PERMIT I
T\ ADDRESS
1 ^O I•f�C-L(„'ILe R� BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
841
WNeR's PLAN CHECK VALIDATION
AMEQTY. ELECTRIC PERMIT FEE
eLL HDNE26G-EZbZ
CONTRACTOR
NAME UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
LIC,No. LIGHTING FIXTURES 10.00/1.00
Dons
ADDRESSDRESS PPLIANCES-RESIDENTIAL 4.00
A
PHONE PANELS 10.00 DATE OF APPLICATION
-
AHC HITECT PANELS (OVER 200 AMP) 20.00 PWNCHECK FEE P.C.No.
OR
ENGINEER se12
/A��,T
LIC.NO. SIGNS TRANS. 3.00 CfSi��
ARCH.OR ENO. PERMIT VALIDATION
ADDRESS SPECIALCIRCUIT 5.00 q(�p
ZIP TEMP.METER OR POLE INS. 2(1.00 SEP
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
_ SERVICE CHANGE 20.00 City of Cupertino
ca
o o LICENSED CONTRACTORS DECLARATION
".u 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
z (commencing with Section 7000)of Division 3 of the Business and
BLDG. EL C PLG. t MECH.
2 i License la Code,and my license is in full force and effect. ❑ ❑ ❑
Z o`� License Gass Lie.Number �
9 Z � Date Contractor �
a y 1
BUILDING PERMIT
¢ ¢ w ¢ OWNER-BUILDER DECLARATION - INFORMATION
o a ° 1SC.- REFER TO ORD
A
; LL r 1 hereby aft irm that I am exempt Irom the Contractor's Lieenu VALUATION S/FT.
H ¢ o`� Law for the following reason.(Sec.7031.5,Businaaand Professions PERMIT ISSUANCE . 10.0
Code:Any city or county which requi Rs o permit m ronstrueL eller,
¢ s- improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR, LIC.NO. ELEC.
O u requires the applicant for such permit to file a signed statement that TOTAL IfPERMIT TO
wK n he is rsua
licensed punt to the provisions of the Contractor's License
Hi> - Law(Chapter 9(Commencing with Section 7000)of Division 3 oflhe
¢ Business and Professions Cade)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ = the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSYR.
by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not mom than live hundred dollars(5500).):
❑ 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 ProfessionsDRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SQ FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
r mcnts art not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
-S or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4(EA) 200 BUILDING USE
builder will have the burden,of proving that he did not build or ire- . . .
RES IND CON PB oleo.
prove for purpose of sale). INDUSTRIAL WASTE INTER. 30.00
❑ 1,as owner of the property,um exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:I lie Contractor's License Law docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
wntracts for such projects with a Contractorfs)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under See.-,It&P,C.for this WATER HEATER W/VENT 6.00
wiser ✓ Date 7 - WATER SYSTEM 5.00
ACC.GATE ACC.FILE NO.
WORK IiRS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm thin I have a certificate ofconsent to self-moue, - ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
ropy thereof(Sec.3800,Lab.C.).
Policy No. Conspany
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is filed with the city inspection division.
O Applicant MISC.- REFER TO ORD. v ❑ N❑ v ❑ N❑
~ w PERMIT'ISSUANCE 10.00 FLOOD ZONE A.L.U.c.
CERTI FICATIi OP.EXEMPTION FROM WORKERS'
W �_ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
C 0 1'fhis section need not be completed if the permit h for nuc TOTAL v❑ N❑ V ❑ N❑
D Z hundred dollars IS 100)or IeaJ
U O I certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
W 1- mit is issued,I shell not employ any person in any manner so as to
U become subject to the Workers Compensation lases of California.
m Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
> r¢Ji NOTICE. TO APPLICANT: If,after making this Certificate of 17
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=C.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 MICROFILM
ance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 6.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I Certify that 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
ordinances and state laws relating to building construction, ,it B0ILER-CONP(3H.P.or1O0,000B.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 harmless the City of misc.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses whichCONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
of of this permit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
cmr Q
Signature of Applicant/ContraDatc
OFFICE COPY