9168 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY 4t2Lf9
BU LDI NG PROJECT I DENTI FI CATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
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`X BUILDING -ELECTRICAL-PLUMBING -MECHANICAL
Ow R'S PLAN CHECK VALIDATION
\/ NAME OTY. ELECTRIC PERMIT FEE
.�
PHONE
CW14S
NAME OUTLETS-SWITCHES=RECEP 10.00/1.00
UC.NO. LIGHTING FIXTURES - 10.00/1.00
QRA DR's
ADDRESS PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARC ITECT PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00 1
ENGINEER
I.C.No. SIGNS TRANS. 3.00 I
ARCH,OR ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 20.00 PAI
AA 1t�
APPLICANTS MOTORS SEE FEE SCH. JUN 11985
ADDRESS
SERVICE CHANGE 20.00 {
00 LICENSED CONTRAC'LORS DECLARATION TEMP.POLE 30.00 City of Cupertino '
¢ U U 1 hereby in f rm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
H rt w (commencing with Suction 7000)of Division 3 oflhe Business and BLDG. ELECT. I.G.PMECH.
r 0 z Professions Code,and my license is in full force and effect ❑ ❑ ❑
, 0.;; License ClassTJ,Lie.Number . e 1
0 m Uate�(_e�x-pe_ContractorC
ams Y+ e' p� ARA I NSQXIJXR BUILDING E MIT
¢ ¢w ¢ OWNER-BUILDER DECLARATION ^�/
INFORMATION
o A MISC.- REFER TO ORD
w ; LL m. I hereby affirm that I am exempt from the Contractor's License VALUATION SIFT.
F u o J Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00
vi Code:Any City or coundy which requires v permit to construct,alter,
¢ ¢ 2 improve,demolish,or repair any structure prior to its issuance.also ELEC.CONTE. LIC.NO. ti ELEC.is 'y
- 0 u mquires the applicant for such permit to file a signed statement that TOTAL
PERMIT TO
X as he is licensed pursuant to the provisions of the Contractor's License
F z a
L..(Chapter 9(commencing with Section 7000)of Division 3 ofthe
i 0 Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ F the basis for the alleged exemption.Any violation of Section 7031.5 1 ST RIES PE CONSTR.
n ; $ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(55001.):
❑ 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 Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law docs nod 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 TOTAL ACREAGE
.
himselfare art
ownerured for sale.
If, dthat such improve- GAS-GAS -11NC.40UTLETS 6.00 I
meets are not omen hrough his or offered for s le.If,ed that s the building
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or no-
provefor purpowofsale.). INDUSTRIAL WASTE INTER30.00 IND CON PB tuner
.
❑ 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:'I he Contractor's License Law does not apply
to an owner of property who builds or,impruves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contraauds)Iicnlsed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I amexempt un der SCC.-,B.&P C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate ofconsent to self-insure. ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(See.3800,Lab.C.) N 1�.
` I'cY Company G <�p�
O R whereby fumemd f �zQr-� FIRE SPRINK ENERGY T@4
Z Z e 'tied ropy is Rled with the city inspection division.
0 ApDi,., MISC.- REFER TO ORD. V-El -El Y ❑ N❑
CCN ..R'f1 ICATE 01'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
L COAIPEMATION INSURANCE PLG.CONTE. LIC.NO. PLG. v❑ N❑ v❑ N❑
CIE. (This section need not be completed if the permit is for one TOTAL
0 Z hundred dollars IS 100)Or less.)
U O 1 Certify that in the peff.umume of lire wok for which this Per- QTY. MECHANICAL PERMIT 't FEE FEE SUMMARY
LL F mit is issued,I shall not e nploy any person it airy manner so as m
Ow becomesE1,Ccd do the WorkerCCom,Cr,,dion Llwsof Calihmmu. BUILDING
C. nam Applica"' ALTER OR ADD TO MECH. 5.00
} W N'O'TICE TO APPLICANT: If,after making fills Certificate of Ex-
r Z_ eruption,you should become subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith complywith FEE
L) such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONST'RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IO,OODO.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
The pr,f.rm.CCC of the work for which this permit is issued(Sea MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
1 certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
• information is Correct. I agree to comply with all city and county PLUMBING
ordinances and state Iaws,relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to 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 expemses which PERMIT ISSUANCE 10.00 CONST.TAX
may a any way accrue vguinsf said City in cousaquance of the
granting of this permit. MECH.CONT. LIC.NO. MECH,
_ TOT"` TOTAL
S re o p leant/Contme or Date
INSPECTOR COPY