C9273 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ONPERMIT NUMBER
BUILDING APPLICATION & PERMIT
AooREss 9 3
I
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PL CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
A F PNONE j
NTRACTORS
AME %, o UTLETS-SWITCHES-RECEP 10.00/1.00
rvo� 11161? LIGHTING FIXTURES 10.00/1.00 4^
CONTRACTOR'S PPLIANCES-RESIDENTIAL 4.00
ADDRESS S
X ; Til/ PHONE �� PANELS IO.00 PATE OF APPLICAT ION
( ARCH EC "' t LAN CHECK FEE P.C.NO.
.-
OR n�vO� �� �-,-- PANELS tOV OO AMP) 20.00
ENGINEER Y!
uc. SIGNS TRANS. 3.00
{ ARCH,OR ENGSPECIAL'CIRCUIT 5.00 PERM�VALIDDATION
ADDnESs ��'Qe4411
�.: �E
i ,) C4ITl E O p zIP 7 Q� I rrEMP.METER OR POLE INS, 20.00
APPLICANT s MOTORS-r, SEE FEE SCH. SEP
ADDRESS 1�E,p
r (• L/.S,[f C.V ('ff�,/J .U/9 7 SERVICE CHANGE 20.00 ®®CC9q
Mo - TEMP.POLE 30.00 city�f Cupertino 0 o LICIiNS1iD CON'T'RACTOR, UECLARA'fION V pertmo
'IGF a v U I hereby affirm that I am lice"sad under provisions of Chapter 9 ISSUANCE DATE
1 N Q N (commencing will Section 70001 of Division 3 of the Business and L a EL T. PL MEC
H n z Peri essipris Code n my license is in full force and effe
(z O m - License Class Lic.Nwnber
'o 0 H w pat Contractor
m f B IL ING ERMIT
K m w OWNIi R:BUILDER DECLARATION ' INFORMATION
w g a h I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
�ipH u_ 00< Law for the following rcasodr(Sec.7031.5.Businessand Professions VALUATION S/FT.
PERMIT ISSUANCE 10.00
Code:Any city or county which ieyuiresa permit loconsuSnc alter, /7y
QQ improve,demolish,or repair any itrwture,prior to its issuance,also ELEC.CONTE, LIC,NO. ELEC.
° R requires the applicant for such permit to file a signed statement that TOTA i� PERMIT TO
u w m LL he is licensed pursuant to the provisions of the Contractor's License
HiQ - Law(Chapter 9(completer, t h Section 700D.I'Division 3 ofthc
P 4 ° Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE / w
2 H p the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
3: _ by:my applicant for a permit subjects the applicant ton civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(8500).):
'i ❑ I,as owner of tLe,pruprny,or r,y employees with wages asggCK FLOW PROTECT. DEVICE 4.00
�I their sole compensation,will do the work,and the structure is not DCC.GROUP ES.UNITS
intended or offered for sale,lSec. 7044. Business and Professions '� DRAINS-FLOOR,ROOF,AREA,GOND. 5.00
J Code:The Contractor's License Law does not apply to an owner of
.F f property who builds or improves thereon,and who does such work. FIXTURES-PER TRAP 5.00 SO.Cr:FLOOR AREA TOTAL ACREAGE
himsclforthraugh his own employees,provided that such improve. GAS-EA.SYSTEM-11NC.40UTLETS 6.00 _
a mutts arc not intended or offered for sole If,however,the building
• or Inrp mPer ent is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
4' builder will have lire burden of proving that he did not build or im- R S IND CON PB Omer
prove for purpose of xaleJ' INDUSTRIAL WASTE INTER. 30.00
A�pp L as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
fI lie[Ilsed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00ASSESSORS PARCEL NO.
F and Professions Code:The Contractor i License Law does not apply
m a,,"W""
of property who builds or improves lhureon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
Contracts for such projects with it contracrod s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 2 ' TRACT NO. PARCEL NO.
I, ❑ I am exempt under See.-,BAP.C.for this WATER HEATER W/VENT 6.00
anon
Owner Due WATER SYSTEM '5.00 %' PCC.DATE ACC:FILE NO.
/ WORKFRS'COMPENSA'IION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate ofconscut mself-insure. ZONING - ENG.SITE NO.
or a certificate of Workers'Compensation Invuance.7or- certified
.copy Ihereof(See.7800,Lab.C). 1
Iso N ornpany '
,Q ❑ Ctr ( py lv bora by fmo isied, I FIRE BPRINK ENERGY L24
{ Z Z ❑ Certified c py is filed wish Thu ci Y ins lion divi. u.
O •huh nal^nom �` MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
~ w PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
TIFI \Tui 1' .X" PTIO, � RS'
LU D - COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG. Y N V N
CL O (Phis section need mol be completed if the permit is for one- TOTAL I ❑ ❑ ❑ ❑
0 Z hundred dollars(5100)or less.)
r U O ' 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in any..rapper so as Io
U w become subject to lire Workers'Compensation Laws of California.
''+ a Dam Applicant - ALTER OR ADD TO MECH. 5.00 BUILDING G,
" } m NOTICE 'f0 APPLICANT: If,after making this Certificate o1'I'.x-
- I Z em prion,you should become subject to the Workers'Compemounno APPLIANCE 5.00 PLAN CHECK
�Y provisions of the Labor Code, you must forthwith comply with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 FEE
CONS]RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm Oct there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(SLL. MICROFILM �!
3097,Civ C.). + HEATING UNIT(TO100,000 B.T.U.) 8.00 ('
Lender's Name H EATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address Q
I certify that I have read this application and start Ona,the above VENTILATION FAN (SINGLE) 4.00 (y
information is correct. I aggro to comply with all city and county - u PLUMBING
�• ordinances and slate laws relating to building construction, and BOILER-COMP(3H.P.or100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon tht 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 or MISC.- REFER TO ORD. I v,
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE '10.00 / CONST.TAX' Q
rt / may in,any is permit. a against said City in consequence of the
graC ng'f this pcmniL / , MECH.CONT. LIC.NO., r MECH.
TOTA TOTAL ' �;
f ea 'bot c )ate CJ ,mow
INSPECTOR COPY