10284 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY zPt' 5'5
BUI LDI NG PROJECT I DENTI FICAT PERMIT NUMBER
aG,LO,Nc APPLICATION & PEF�f 10284
fe`JDREss„
1�Ea BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNERS PLAN CHECK VALIDATION
+r
PTY. ELECTRIC PERMIT FEE
ZA1 60
� 1"• PHONE,�,r���
CONTRACTORS n UTLETS-SWITCHES-RECEP 10.00/1.00
d-vC . C•- LIc.No. LIGHTING FIXTURES 10.00/1.00 -
rorvrRacroRs APPLIANCES-RESIDENTIAL 4.00
CONTRAS A'
..lS G/1/l� S.S� PHONE afS PANELS 10.00 _ DATE OF APPLICATION
onCR,TEGT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.O.NO.
ENGINEER
uc.NO. SIGNS TRANS. 3.00 C3 A
ARCH.
ENG. SPECIAL CIRCUIT 5.00 PER"^ - ION
ZIP TEMP.METER OR POLE INS. 20.00 DEC 11 jggE
APPucarvrs MOTORS SEE FEE SCH. 1 IL`�BJ
APPLICANT
n
sS C/f e�F �r+7�' SERVICE CHANGE 20.00 City.of Cupertino
Or
o LICENSED CONTRACTORS DECO ATION TEMP.POLE 30.00
a o u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE GATE
.Naw (commencing with Section 7000)pf Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H o i Professions Code,and my license is in full force and if•c1.7 ❑ El 1:1 i m¢ License Clies_�!_3E Lia Number /,'2/$.49
F y r J Date Contractor AtlZ-isi
a se f BUILDING PERMIT
or ¢o re 4 OWNER-BUILDER DECLARATION INFORMATION
X ; n,r I hereby affirm Hurt 1 am exempt from the Contractor's License MISC.- REFER TO ORD
VALUATION $/FT.
.. O 4 Law for the following reason.(Sec.7031.5.Business and Professions 10.00
PERMIT ISSUANCE
Code:Any yor county which requiresapermdtoconstruct,alter,
Qa ¢o improve,dem 'sh,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC:NO:---�_ ELEC.
¢ requires the app' ant for such permit to file a signed'statement that - TAIL
6 w m y is is licensed puts at to the provisions of the Contractors License PERMIT TO
Ha, Law(Chapter9(cou tenting Section 7000)of Division 3 of the
a Business and Professio Code)or that he is exem It from and QTY. PLUMBING PERM FEE
as o
¢ o the basis for the alleged e. mption.Any violati of Section"7031.5 STU FIT
Tv CONSTR.
by any applicant for a pem' subjects the up cant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
W � of not mo«than five hom re ollarS(SS .):
f ❑ I,as owner of the prove ,or employees Will,wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.units
their sole compensation,will do a ork,and the structure is not
intended or offered to, sale(Sec. 044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License aw Gas not apply to an owner of
properly who builds or lmpro sther n,and W ho d oes SnC It Wofk FIXTURES-PER TRAP 5.00 �. SQ FT.FLOOR ARE/ TOTAL ACREAGE
• himself or through his own ployees.p vided that such intDrove-
ments are not intended o ffered for sale. ow ever,the builJm GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sol ithin one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have th urden of proving that IT did not build or int- BUILDING USE
RES IND CON PB Other
prove for purpose sale.). INDUSTRIAL WASTE INTER. 30.00
O I,as owne of the property,am 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: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)licensed pursuant In SEWE -SA ITARY-S ORM EA.200f1/10.00
lire Contractor's License Law. �. TRACT NO. PARCEL NO.
❑ lam exempt under Sec ,B.&RC.lin this / WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
r• ACC.DATE ACC,FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure' ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a -ertified
copy thereof(Sec.3800,La b.CJ. ,,//
Policy N .ompany_ 411e
0 ❑ Cc lifie Copyvhe«b furnished. FIRE BPRINK ENERGY T 14
Z Z >4. Certified copyy�r is f with Lhe city inspection division, MISC. REFER TO ORD.
O APPicant�/ Q--�L--(� Y ❑ N❑ Y ❑ N❑
� N CERTIFICAIE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A_L.u.C.
LU > COMPENSATION INSURANCE PLG.OONTR. LIC.NO. PLG.
C O (This section need not be completed if the permit is for one ,C.9��d�'. / TOTAL�.3/. v❑ N❑ v ❑ N❑
5 Z hundo, do1lars(SI00)or less)
U O I cert,- that in the perl'ormence of the work For which this per CITY. MECHANICAL PERMIT FEE , FEE SUMMARY
LL H mit is issue shall not employ any person in any mannerso as to
O W become subjec the Workers'Compen,at (California.
s Dae ' I!canl ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE TO APPLIC ,after making this Certificate of lix-
F Z amplion,you s coon object to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
Drovtsiot the Luber Code, to most forthwith comply with FEE
U such provisions or this permit shall earned«coked. AIR HANDLING UNIT(TO 10p00C.F.M.) 4.00
CONSTRUCT ION L17NDING AGENCY AIR HANDLING UNIT(OVER 10,000C.F.M.) 6.00 SEISMIC FEE
1 0, affirm that there is.a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the perl'otma f the work for which this permit is issued(See. MICROFILM
3097.Cu,.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's AdH EATING UNIT IOVER 100,000 B.T.U.19.50 ELECTRIC
dress
I certify I at 1 have read this application a state that she above VENTILATION FAN (SING LEI 4.00
O information is correct. I Sgtec to comply with Al city and county PLUMBING
m
ordinances and state laws relating building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP Ws.r 100,000 BTU)SEE FEE SCH. MECHANICAL
'above-mentioned property for inspection purposes.
(we) agree to savd.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 acer against said City in consequence of the
gomfir,of it,, n'
i eo . MECH.CONT. LIC.NO. MECH.
/a Date TOTAL TOTAL
Signature of Applicant/Contractor
OFFICE COPY,