C9361 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT ^
ADDRESS/(go BUILDING - ELECTRICAL-PLUMBING-MECHANICAL b
OWNER'S LAN CHECK VALIDATION
NAME PHONE QTY. ELECTRIC PERMIT FEE
® 36
C cTORs
NAME ME OUTLETS-SWITCHES-RECEP 10.00/1.00
'C LIC.NO. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S PPLIANCES-RESIDENTIAL 4.00
ADDRESS
k,1 r PHONE PANELS 10.00 DATE OF APPLICATION
R E PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE D.C.NO,
OR
ENGINEER
y, uc.NO. SIGNS TRANS. 3.00
ARC IT OR ENG. F. SPECIAL CIRCUIT SOO PERMIT VALIDATION
ADDRESS ESS .
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 /
o o LICI:NSI:D CONTRACTORS D1iCLARATION
TEMP:POLE 30.00 �4,xll
S
V U I hereby at' rt.that I am licensed under provisions of Chapter 9 ISSUANCE DATE
¢ 2 1° (clonan,acmg with Section 7000)of Division 3 of lire Business'still BLD ELECT. P MBCH.
wz Professions Code,and license is in full f...c ride ff}et
Z o u,- License CF ss Tic.No n.bei-j" k5 ❑ ❑
Q v, RMIT
Dale /{��)�Con tractor / sC
2M ¢ O 'NFR ,Ii-BUILDER DECLARATION BUILDING P ION
E o a ° MISC.- REFER TO ORD INFORM ION
wLL N I hereby affirm that I am exempt from the Contract.,',License VALUATION $/FT.
F .. o ¢ Law for the following reason. 7031.5,Businessand Professions PERMIT ISSUANCE 10.00
w Code:Any city or county which requiresa permit loconstruct,alle,.
ar u G 2O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTH. LIC.NO. ELEC. 140
O u requires the applicant far such permit to file a signed statement thin TOTAL p RMIT TO
F
m he is licensed-panuant to the provisions of the Contractor's License
H z i
Law(Chapter 9(commenciagwith Section 7000)of Division 3 of the /
4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
rc H o the basis for the alleged exeamption.Any violation DfS.clion 7031.5 S TR. If
n ; m by any applicant for a permit subjects the applicant to A civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than tivehundred 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,anti lire structure Is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:1'hc Contractors Li¢nse Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such• improve-
b
meats are not intended or offered for sale.If.however,the uilding GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have the burden of proving that he dict not build or im-
provefor Purpose ofsale'). INDUSTRIAL WASTE INTER. 30.00 E5 IND CON PB Other
❑ I,as owner 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.
gild Professions Code: I lie Contractor's License Low docs not apply .1
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 punuwL to -
tlleContranor'sLicenseLaw. SEWER-SANITARY-STORM EA.200ft/10.00 F TRACT NO, PARCEL NO. ,
❑ I am exempt under See ,B.&P.C.for this WATER HEATER W/VENT 6.00 -
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACCaFILE N0.
WORRIiRS'80M1'F,NSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby al fi,m [hal I'have a certificate ofconsent to sealf-insure, ZONING ENG.'SITE NO,
or a certificate of Workers'Compensation Insurance,orcertified
copy thereof(Sec.3800,Lab.CJ. -
Policy No.�,st�.�Comp�nyy�y[/r
O ❑ CerDl'fedcopy'i,hereby if mshC ����[ FIRESPRINK ENERGY T-24
��QQ Cerlll'Icd e ry is filed will, must �Instc ton diMiilon. MISC.- REFER TO ORD.
z ,\pp7tcaIT e,,-/J� 0 _ Y ❑ N❑ Y ❑ N❑
CC T CERT C,TI'Ols I:)Iile_IO�WORKERS' PERMI ISSUA CE 10.00 FLOOD ZONE A.L.U.a. 7
LU > COMPF-NSA1ION INSURANCE PLG.CONTR. LIC.NO. PLG.
d O (This section need not be completed if the permit is for one .TOTAL Y❑ N❑ Y ❑ N❑
=) 2 hundred dolla.s($100)or lass.)
V O 1 certify that in the performance of the)Fork for which this per OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1= all is issued,I shall not employ an Pers. "n any mann..ao as or
U became subject to the Workers'C m s' n Laws of Culifunlia. S�
V a Uwe Applicant - ALTER OR ADD TO MECH. 5.00 BUILDING
} rA IJDTICI>TO A1'1'LICAN'I': IL, to n ing this Certificate of rix-
' ? comfca,you should become spbject the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
-provisions of the labor Code, von all fnrlhwith comply with FEE
V such provisions or this peril shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY
AIR HANDLING UNIT(OVER I0=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is r construction Icnt is issued
for EXHAUST HOOD(WITH DUCT) 5.00
lira ,Civ.C.). of the work for wl ich-this permit is issued(Sec. MICROFILM
30ndr,', .C.). �r HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that l have read thiapplication and star,that the above VENTILATION FAN (SINGLE) 4.00
information n correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to 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 (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 which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
granting ofthis pemliL MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signa ur o plicant/Contractor we
INSPECTOR COPY -
, I