9328 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT IDENTIFICATION PERMIT NUMBER
nUILDING APPLICATION & PERMIT 93
28
ADDRESS
�. BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNERS PLAN CHECK VALIDATION
"AME QTY. ELECTRIC PERMIT FEE
PRONE
NAMERAc R UTLETS-SWITCHES-RECEP 10.00/1.00
uc.No. LIGHTING FIXTURES ' 10.00/1.00
T ADDRESS Acroa' - APPLIANCES-RESIDENTIAL 4.00
AO
PHONE PANELS 10.00 1,
DATE OF APPLICATION
OR
C PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
UC.No. SIGNS TRANS. 3.00
ARCH OR ENG.
SPECIAL CIRCUIT 5.00 P (DATION
ADDRESS
ZIP q EMP. METER OR POLE INS. 20.00
APPLICANT is MOTORS SEE FEE SCH. JUL �. � I��7
ADDAOR Ess
SERVICE CHANGE 20.00
o a Z City of Cupertino
'09 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a u U 1 hereby affirm that 1 am licensed under provisions o'Chapter 9 ISSUANCE DATE
y a m (commencing with Section 7000)of Division 3 of The Business and BLDG. ELECT. PLG. MECH.
r m z Professions Code,and my license is in full force and effect. ❑ ❑ ❑ `
z o,A,- License Class Lic.Numbers.a if
77"'."'�
o T t w Date Contractor
P: y 2 BUILDING PERMIT
Ir ISu OWNER-BUILDER DECLARATION INFORMATION
w 3 H H I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
VALUATION
Fu0 < Law for the following reason.(Sec.7031.5,Bustnessand Professions PERMIT ISSUANCE - 10.00
Code:Any city or county which requires a peen it to construct,alter,
Re, Q Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
d w m m he is licensed pursuant to the provisions of the Contractor's License
rz >
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
a Business and Professions Code)or that he is exempt therefrom and QTV. PLUMBING PERMIT FEE
r 0te basis for the alleged exemption.An
o Professions
a Any violation is exempt Section 7031.5
B ORI TYPE CONSTR.
F, by by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars($500).):
❑ 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 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 TOTALACREAGE
himself or through his own employees,provided that such improve-
mentsare not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00
or improvermot is sold within one year of completion,the owner- GAS EASYSTEM-OVER 4 (EA) 200
builder will have the burden of proving that he did not build or hit- - . . .
- BUILDING USE
prove for purposeof saleJ' INDUSTRIAL WASTE INTER3000 RES IND CON PB Omer
. .
O 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(See.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 � I
contracts for such projects with a contractims)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Con Nicrv's License Law. TRACT NO, PARCEL NO.
❑ I:unexemptunder Sec. ,B.&I'.C.forthis WATER HEATER W/VENT 6.00
rcacm
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORK ERS'COnIPI�NSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby al Erm thaLl hav2 a certificate of comm to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE N0,
copy thereof(See.3800,Lab.C.).
Policy No. Company -
O ❑ Certified copy is hereby furlshe . FIRE SPRINK ENERGY T 24
z�Z ❑_Cert ifico is it file) w'Oi the city inspection division.
-Ap`pllceot MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ No
~ - IPERMIT ISSUANCE 10.00
w Cli y IC.\TE OP iXEMPTION FROM WORKERS' FLOOD zoNE A.L.u.c.
W COMPENSATION INSURANCE. PLG.CONTR. LIC.No. PLG.
* CL Z This section need not he completed if the permit is for one TOTAL y AY❑ N❑ v ❑ N❑
hundred dollar.(5100)or less.) l-
U O I eertlfy that in the perl'mo unce of the work I'or which thi,per. CITY. MECHANICAL PERMIT FEE FEE SUMMARY
IL 1- mit is issued,1 shall not employ any person in any manner so as to
O become subject to Lite Workers'Compensation Laws of California.
11.1 a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE 1'0 APPLICANT: If,after making this Certificate of E.-
F.. ? 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 10,000C.F.M.) 4.00
1 CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10DWC.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 of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). H EATING UN IT(TO 100,000 B.T.U.) 8.00
Lender's Name
HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lenders Name ELECTRIC
Icertify that l have read this application and smm Olaf the above V ENTILATION FAN (SINGLE) 4'.00
• information is correct. I agree to comply with Al city and county PLUMBING
ordinances and state laws relating to building nmstruc"on. and BOILER-COMP(3 H.P.or 100,000 B.T.U.1 6.00
hereby authorize representatives of this city fn enter upon hire BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep IONDIess the City of Misc.- REFER TO ORD.
Cupertino against liabilities,judgmems, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
granting of this permit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Sign plica Contractor ) L
INSPECTOR COPY