9263 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI MCATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
/D ING - ELECTRICAL-PLUMBING-MECHANICAL 9263
E 's PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
i P E
CONTFrACTOO TOUTLETS-SWITCHES-RECEP 10.00/1.00
�-�[•NAME 1� /
uc.No. !` LIGHTING FIXTURES 10.00/1.00
r. NTA Rs '� �( � qq APPLIANCES-RESIDENTIAL 4.00
ADORE (;Jli•y��!�rl-/',�J
//O ti FHONE (•� �' �' PANELS 10.00 GATE OF APP CATION
RCHlrscr
OR ' PANELS (OVER 200 AMP) 20.00 LAN CHECK FEE P.C.NO.
O
ENGINEERLIC. 3
c.No. SIGNS TRANS. .00 ,
ARCH.
DD Ess ENG, CIRCUIT 5.00 - PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 PAir x
APPLI CANTS
ADDRESS MOTORS SEE FEE SCH. JUL
SERVICE CHANGE 20.00 12 7985
O o LICENSED CON'CRACI'ORS DECLARATION TEMP.POLE 30.00 City
` p
¢ u heby affum that I am licensed under provisions of Chapter 9 City O1 yA ATE
(c<�))nmreencing with Section 7000)of Division 3 of the Business and .. BLDG. ELECT. P G MECH. r�
m z Pr6fessions Code,and d/license is in full force nd cffT' _ {{ ❑ 1:1
❑
z o w - Liccnsc Class /� ,_L�Lic.Number-d S res
w Dalc Contractor
a x BUILDING ERMIT
¢ c w Q OWNER-BUILDER DECLARATION INFOR ATION
u0uMISC.- REFER TO ORD '
K 3 LL r 1 hereby affirm that I am exempt from the Contractor's License - VALUATION
FLLOJ Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code'.Any city or county which requires a permit to construct,alter,
en Q 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO, ELEC.
ca
- O G requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO -
u w m he is licensed pursuant to the provisions of the Contractors Liccnsc
H z i
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r o the basis for the alleged exemption.Any violation of Section 7031,5
ST S T PE CONSTR.
dg °1 by any applicant(..apermit subjects the applicant too civil penalty
of not more than five hundred dollars f$500)I ALTER-DRAIN& VENT-WATER (EA.) 5.00
❑ I,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 Profession,, DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code.The Contractors License Law does not apply to an owner of
property who builds of 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 improvm
near,are not intended or offered for sale If,however,the building GAS-EA.SVSTEM-I INC-4 OUTLETS 6.00
or imn
provement is sold within one year of completion,the ower- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im_ BUILDING USE
Love for purpose of safe,) INDUSTRIAL WASTE INTER3000 R IND CON PB Omer
❑ I,as owner of the property,am exclusively contracting with . .
❑ ❑ ❑ ❑
l licensed contractors to construct the Project(Sec, 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 --x ASSESSORS PAR CEL NO.
and Professions Code:I'he Contractor's License Law does not apply
to an owner of property who builds or inhp...v,thereon,:uhd who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to
life Contmetor's License Law. - SEWER-SANITARY-STORMEA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt un der Sea ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner- Dat, WATER SYSTEM 5.00
ACC.DATE ACC.FILE N0.
WORKERS'COMPENSA'IION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab CA
Policy No. Comp' y
O ❑ Certifie p is y. no
FIRE SPRINK ENERGY TY4
Z Zrtif d co f Yh. h• city 'ns,,ctioH division.
O Ahplicalt �-- MISC.- REFER TO ORD. y ❑ N❑ y ❑ N❑
CC y CER'I'I-WA'I'1101'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.o.
W COMI'EN'SATION INSURANCE PLG.cOrvrR. uc.No. PLG.
0- Z (This sec on need n.t he completed if the permit is for One TOTAL V❑ N❑ y❑ N❑
hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT ,FEE FEE SUMMARY
LL H mit is issued, 1 shall not employ any person in any manner so as to
U become subject to the Workers'Com PensatlonhLaws of California.
i Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE TO APPLICANT. If;after.making this Certificate-of Ex-
(_ Z_ enhplion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provi,ions of the Labor Code, you most forthwith comply with FEE
U such provisions or this Permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.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.). HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name HEATI NG UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Andre ss
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 state laws .dating to building construction, and BOILER-COMPI3 H.P.or 100,000 B.T.U) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) Iti to save,Nindelimify 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 y Beenc against said City is consequence of the
in of erahi[ MECH.CONT. LIC.NO. MECH.
TOTAL
TOTAL
5ur of df ontruclor o[e
J INSPECTOR COPY 1. E '