9274 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
PUILDING APPLICATION & PERMIT
MI?
ADDRESS
611
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 9274
O R'S 5�0(5 PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
® vHorvE
NOME crD UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
LIC.No. LIGHTING FIXTURES 10.00/1.00
ftitifix T A AC YOR's APPLIANCES-RESIDENTIAL 4.00
ADDRESS
RHONE 99 PANELS 10.00 DATE OF APPLICATION
Cm Ci PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC,NO. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
PAI
ZIP EMP.METER OR POLE INS. 20.00 D1f�
APPLICANTS MOTORS SEE FEE SCH. JUL 12 IJ85
AODRE55
SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECL VTION TEMP.POLE 30.00 City of Cupertino
< U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and BLDG, ELECT. PLO. MECf
ry i Professions Codc I I,1 license is in full for •u d •f 1'c ❑ ❑ ❑
z o w- License Class �L1�.i, Number
9 z r D Uate Contractor t
a Y s -a Ct BUILDING PERMIT
w OWNER-BUILDER DECLARATION INFORMATION
A o A MISC.- REFER TO ORD
ru N 1 hereby collo that I am exempt Crn.5 the GUosand P s License VALUATION
3: Law hereby followings II ant exec. t from he Cori andl'rofcssions PERMIT ISSUANCE 10.00 S/FT
r - Code:Anycity orcounty which requires a pemoit to construct.abet.
re K Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.GONTR.• LIC.ND. ELEC.
0 LL requires the applicant for such permit to file a signed statement that TOTAL p MIT TO 1
u w m he is licensed pursuant to the provisions of the Contractor's License
� Za
Law(Chapter 9(commeacing with Section 7000)of Division 3 ofthe
4 er Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
ES o the basis for the alleged exemption.Any violation of Section 703 t.5 STORIE - T PE CONSTR.
by any applicant for a permit subjects lite applicant to a civil penally ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more loon five hundred dollars 05000.):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do lite work,and the structure is not OCC.GROUP REB.UNITS
intended or offered for sale (Sea 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 does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such'in
prove.
ments are not intended or offered for sale.If,however,the budding GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
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.). INDUSTRIAL WASTE INTER3000 RES IND PB Omer
❑ I,as owner of the property,am exclusively contracting with . .
❑ ❑ CN ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS CEL NO.
and Professions Code:The Contractor's License Law docs not apply
to an owner of property who builds or improves Bteteo .and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractods)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&RC.Ibr this WATER HEATER W/VENT 6.00
it reason
Owner Date WATER SYSTEM 5.00 ACC.OATE ACG FILE NO,
WORK I;RS'COM PENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby atfirn that 1 have a certificate of consent to scb6insurc, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
I'olicY N Company 111 ex eoligi
O err itiedcopy is hereby fm t-told'-"- FIRE SPRINK ENERGY T-24
Z_ Z ❑ Certified opy a it the city e (ion division. MISC.- REFER TO ORD.
O Applicant Y ❑ N❑ Y ❑ N❑
"`~ wPERMIT ISSUANCE 10.00 FLoODZONE A.LU.C.
CEk'1'I PICA'I'Ii0� .XEMI'fION ERO�1 WORKERS'
LU COMPENSATION INSURANCE PLG.CONTR, LIC.NO. PLG. V❑ NO Y F] N❑
CL Z (This section need not be completed if the permit is for one TOTAL
hundred dollars($100)or less.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mil is issued,I shall not employ any person in any manner so as to
Ow become suhject to the Workers'Compensation Laws of Califurnia. BUILDING
EL Date Appbcam ALTER OR ADD TO MECH. 5.00
} to NOTICE TO APPLICANTLIL after making this Certificate of Ex-
F 2 emotion,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 10SMCF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.EM.) 6.00 SEISMIC FEE
I hereby affirm that Blare is a conSUnctiou lending agency for EXHAUST HOOD(WITH DUCT) 5.00
re performance
r ormance of tire MICROFILM
e work far which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00
a .
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)9.50 -
Lender's Address ELECTRIC
I certify that I have read this application and state that the above V ENTI LATION FAN (SINGLE) 4.00
• information is correct, I agree to comply with all city and cowtly PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
f hereby authorize representatives of this city to ewer upon the BOILER-COMP (Over 100,000BTU)SEE FEESCH. 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,judglnens,.co,ts send expenses which -PERMIT ISSUANCE 10.00 ONST.TAX
pray in way accrue ainsl said City in consequence of the
BOBntin Otis permit MECH11_ .CONT. LIC.NO.' MECH.
TOTAL TOTAL
ZA Ignm re of APpl a Cmitmctor arc
INSPECTOR COPY '