9266 (2) APPLICANT TO FILL-IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS �A�NG- ELECTRICAL-PLUMBING-MECHANICAL
Inl4q-
/ 9266 nv6
OWNER PLAN CHECK VALIDATION N
NAMEQTY. ELECTRIC PERMIT FEE
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CUNa TOR UTLETS-SWITCHES-RECEP 10.00/1.00i / 1LIGHTING FIXTURES 10.00/1.00T ACTOR'S ' - APPLIANCES-RESIDENTIAL 4.00E55
PANELS 10.00 DATE OF APPLICATION
WmtHI7ECT PANELS (OVER 200 AMP) 20.00
ENGINEER PLAN CHECK FEE P.C.NO.
OR
uc.No. SIGNS TRANS. 3.00 RAIQ
ADDRESS EN¢ SPECIAL CIRCUIT 5.00 PERMIT ATION
ZIP TEMP.METER OR POLE INS. 20.00 JUL
ADORES MOTORS SEE FEE SCH. h�
ADORE
SERVICE CHANGE 20.00 City of Cupertino
00 LICENSED CONTRACTORS DECLARATION - TEMP.POLE 30.00
F ca w 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. PLG. MECH.
o o I'rafessions Codu,nn�my 'tense is in full force Q pf f•ct ❑ E] ❑
z o w - License Class Lic.Numher�
_ H w Dam Co:ItrattOr
a y E u BUILDING E MIT
a o n ° OWNER-BUILDER DECLARATION INFOR ATION
w ; LL m I hereby attire That I am exempt from the Contractor's License MISC.- REFER TO ORD VALUATIO S/FT.
F LL o a Law for the following reason.(Sec.70715.Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,after,
re A, ¢ 2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
A
E e u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w m he is licensed pursuant to the provisions of the Contractor's License
H z a
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
r m the basis for the alleged exemption.Any violation of Section 7031.5 E CIONSTR,
by any applicant for a permit subjects life applicant to a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT,DEVICE 4.00 OCG GROUP RES.UNITS
their sole compensation,will do the work.and the structure is net
intended or offered lar sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code.The Contractor's License Law dues not apply to on owner 01' -
property who builds or Improves thereon,and who does such work FIXTURES-PER TRAPS.00 5°.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such im Drove-
ments are not intended or offered for sale.If,however,the building GAS-EA.SV SYSTEM OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or im- - . BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 E IND ,CON PS 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.
and Professions Code:The Contractor's License Low does not apply
to an owner of property who buildn or improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts for such projects with a contractor(,)lira"sed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
reason am exempt under Sec. ,B.&ItC.lorthis WATER HEATER W/VENT 6.00 2 Od
Owner Dare WATER SYSTEM 5.00 O ACC.DATE ACC.FILE NO,
WORK F.RS'COMPENSA'fION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby at1'inn that I have a certificate of me consent to se fGinsurc. ZONING
• or a certilicof Workers m
Copensation Insurume,or u teHilN ENG.SITE NO,
copy thereof(Set.3800,Lab.0
Pokey N'o. Compan
O ❑ Certil icd co here m' FIRE SPRINK ENERGY T 24
Z Z , cant ificd t p t tl a city inspection division. MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N❑
O
~ yPERMIT ISSUANCE 10.00
- Cfi R'I'I PICA'I'E O I' :X EM PTI ON FROM WORKERS' ` FLOOD ZONE A.L.U.C.
LUQ COMPENSATION INSURANCE PLG.CONTR. LIC.NO, PLG. W ❑
EL Z (This section need not be completed it the permit is I'or one TOTAL17460
YE] N❑ v ❑ N
hundred dollar'IS 100)or less.)
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,1 shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California. BUILDING
Q. Date Appl"°nt ALTER OR ADD TO MECH. 5.00
} W NOTICE TO APPLICANT: If,after making this Certificate of Es-
F 2 eruption,you should become subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK
provisions o1the Labor Code, you must forthwith .,,only with FEE
U Such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 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.CieC.L 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 I 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-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city t" 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 pERM1T ISSUANCE 10.00 \ CONST.TAX
uz
c against said City in cmusequcncc of the
F,
ECH.CONT. LIC.NO. TOTAL
ontractor a
INSPECTOR COPY