9420 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG'PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING ORIESS APPLICATION & PERMIT 9420
ADORES
m/A ,N _ _ BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
"A QTY. ELECTRIC PERMIT FEE
// �vvHDNE
NA
M1EHacTORs OUTLETS-SWITCH
ES-RECEP 10.00/1.00
n.
uc.No. s LIGHTING FIXTURES 10.00/1.00 -
C,ONTRACTOR's PPLIANCES-RESIDENTIAL 4.00
ADOREss
/ PHONE PANELS 10.00 DATE OF APPLICATION
AHUNI I eci PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
L)c,NO. SIGNS TRANS. 3.00
ARCH.OR ENG, PERM�.VALIOATION
ADDRESS SPECIAL CIRCUIT 5.00 hAy
ZIP EMP.METER OR POLE INS. 20.00 AUG
I
ADDRESSr5 MOTORS SEE FEE SCH. f1U� J19Qfa
ADDRESS
SERVICE CHANGE 20.00
r� o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 City of Cupertino
u U I hereby affirm that 1 am licensed under provisions at Chapter 9 ISSUANCE DATE
a z w Icommeecmg with Section 7000)of Division 3 ofthe Business antl
F„ a A BLDG. ELECT. PLG. MECH.
r- D i Professions Codc, nd my license is in full force nd NFL
❑ ❑ ❑
z'o m 0 Liccnsc Class Lic.Number
2 o aa Uule$S�' _Contractor 16of F4
a x M BU DING PERMIT
rc Q w OWNIiR-NUILUER DECLARATION 1 FORMATION
X o d s- I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u ,A Y P VALUATION $/FT.
F u o j Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00 n
Code Any city or county which requires a permit to construct,alter, _
G
FO improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. 0/'7
a wO a,requires the applicant for such permit to file a signet)statement that TOT C(// PERMIT TO
m w he is licensed pursuant to the provisions of the Contractor's License
H z a Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
Itueiness and Professions Code)or that lie is exempt therefrom and QTY. PLUMBING PERMIT FEE
r c f ie basis for the alleged exemption.Any violation ol'Section 7031.5 STORIES TYPE CONSTR.
m by any applicant fora permit subjects the ap,licantto a civil penalty ,
.1 not more than five hundred dollars(S500).): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ 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 sl ructure 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
properly 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-
mentsarenotintendedoroffered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA ) 2.00
builder will Iwve line burden of proving that he did net build or ire- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 IND CON PB Ooh.,
❑ I,as owner of the property,am exclusively contracting with .S ❑ ❑ ❑ ❑
licensed contractors it) construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 SSESSORS PARCEL NO.
and Professions Colic:The 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 for such projects with a contractorls)licensed pursuant to SEWER-SAN V-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ l am exempt under Sec,-,W&P.0 for this WATER HEATER W/VENT 6.00
reason
Owner - Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSAI ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have u certificate of consent tD Self=insure, ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copythereof(Sec.3800,Lab.C.).
Polic 'e. Co... 'I /ze-g n/T
O Ccrlifiedoy isI furaed.hFIRE SPRINK ENERGY T-24
Z ZO ncJe"f
e copy d with the city inspection division. MISC.- REFER TO ORD. Y(] N E] Y❑ NC]
=r 2 .RTIFICATE 017 EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.LUC.
LL COWWENSWION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL D (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
Z) Z liundied dollars(8100)orless)
C-) 0
OI certify that in the performance of the work torwhlch this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL - mit is issued,I shall not cnprloy any person in any mare,so as io
U become subject to the Workers'Compensation Laws ol'California.
U y Dal`' Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NO'T'ICE TO APPLICANT: IL after making this Certificate of Ex-
� 2 emptiuq you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK -
provisions of the Labor Code, you must forthwith comply with FEE
r U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1000011F.PA) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is unstruction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
ibe wrtounmee of the wofk or which this permit is issued(Sec. MICROFILM
3097,Civ C.), I HEATING UNIT(TO 100,000 B.T.U.) 8.00
lender's Name H EATING UNIT(OV ER 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 correct. 1 agree to comply with all
city and county PLUMBING
ordinances and state laws relating to building orelruclion, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize represematives of this city to enter upon the BOILER-COMP (Over 100.000 BTU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(Wa)
agree m ave, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino again iabililics�J.ldgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any��ys aceru ,'�mst said City in nmseq ucnee of the
•ranting of 4svpcnnmtJ MECH.CONT. LIC.NO. MECH.
/ s_c2S TOTAL TOTAL' -rl) .
Ignatureno(Appbcant/ ontractor Date
INSPECTOR COPY