09646 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFIqAfA904 PERMIT NUMBER
AG APPLICATION & PERMIT 09646
ADDRESS
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER 5Z PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
® ONE
COTRACTORSUTLETS-SWITCHES-RECEP 10.00/1.0
/ �rc LIC.NU LIGHTING FIXTURES 10.00/1. 0
CONTRACTOR s
ADDRESS PPLIANCES-RESIDENTIAL 4.00
A
A;V
e;=14 PHONE PANELS IO.00 DATE OF APPLICATION
ORHCHrtECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. _ SIGNS TRANS. 3.00 u.
noo Ess ENG. -_ SPECIAL CIRCUIT $.0.Q PERMIT VALIDATION
ZIP ITEMP. METER OR POLE INS. 20.00
APPLICANT
ESSTs - AUG
AUS �e9�oo SEE FEE SCH.MTR
SERVICE CHANGE 20.06 City Of Cupertino
0 O o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
Fu w 1 hereby aflirm That Iain licensed under provisions of Chapter 9 ISSUANCE DATE
Q n (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
D Z Professions Code,and my license is in full force and effect. E]
a, O H - License Class e1,-Lic.Number
2 o H Date__p:J� Contractor
It x -+ O/���` " L - B LDING PERMIT
¢ ¢ w ¢ OWNER-BUILDER DECLARATION
A O A u INFORMATION
X ; LL N I hereby affirm That I am exempt from file Contractor's License MISC.- REFER TO ORD
oa Law for the following reason.(Sec.7031.5,Businessand Professions pERMIT ISSUANCE 10.00 VALUATION g/FT.
� LL Code:Any city or county which requiresapermit to construct,alter.
¢ ¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.DDNTR, LIQ NO. ELEC.
- o¢ requires the applicant for such permit to file a signed statement that TOTAL
a w m he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
Fri
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
F i ao Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE lC r/L
BE 1-$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
> > by any applicant for a permit subjects the applicant too civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ 1,as owner of the property,or my employees with we
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,AR EA,COND. 5.00
Code:The Contractors License Law docs not apply to an owner of
property who builds Or iriproves thereon,and who does such work FIXTURES-PER TRAP 5.00 50.FT.FLOOR AREA TOTALACREAGE
• himself or through his own employees,provided that such nr'm,,-
.cuts are not intended or offered for sale.IL huwevcr,the building GAS-EA.SVSTEM-I1NC.4OUTLETS 6.00
or improvement 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 nobbuild or in - . - . . BUILDING USE
RE IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑
❑ I,as owner of the properly,am exclusively contracting withEN
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 a55E55OKS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts lin such projects with a contractors)licensed pursuant t., SEWER-SAN V-STORM EA.2001[(10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.for fills WATER HEATER W/VENT 6,00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSA1lON DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate of consent to self-insure. ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sce.3800,Lab.CA)
Policy No. Company.J-�... 5:
O ❑ Certified copy is hereby l'Grfi(died. RE SPRINK ENERGYTT4
Z 2 ❑ CertiI I copy/i�fled with the fy inspection division,
O Applicant .-'P MISC.- REFER TO ORD. y❑ N❑ v ❑ rv❑
~ w �� PERMIT ISSUANCE 10.00
CER'I'I FICATE OIt BX ITN PTI ON FROM WO R K E RS' FLOOD ZONE A.L.U.C.
LLI > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O ('this section need not he completed if.the pennil is for one TOTAL Y❑ N❑ Y 1:3N❑
::) 2 hundred dollars(5100)or Iess.l
U O 1 certify that in the perl'urm:nme of Iho work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mil is issued,I shall not employ any pcaon in any manner so as to
O W become subject to the Workers'Compensat ion Laws of California.
Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>_ N NOTICE'10 APPLICANT: If,after making this Certificate of lix-
F 2 emption,you should become subject to the Workers*Compensation APPLIANCE 5.00 PLAN CHECK
provisions of file Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10J100C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNITIOVER I0,000C.F.M.) 6.00 SEISMIC FEE
I hereby aflirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this pennil is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and stale laws relating to building construction, and BOILER-COMPI3 H.P.or 100,000 B.T.U) 6.00
hereby authorize representatives of this city lc enter upon the BOILER-COMP (Over 100,000 BTUI SEE FEE SCH. MECHANICAL
above-mentioned properly for inspection purposes.
(We) agree 10 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 Of L lis pennil. MECH.CONT. LIC.NO. MECH.
14� � -�-� 'r oTAL TOTAL C
Sf[rlafrure o Ap ican!Cnn c or Date /
INSPECTOR COPY