9160 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI F[CATION PERMIT NUMBER
aDrLDrNG APPLICATION & PERMIT UILDING-ELECTRICAL-PLUMBING-MECHANICAL
�� ��
ADDRESS
O s� Z
OWNER'S PLAN CHECK VALIDATION
NAME fall
-r 4 QTY. ELECTRIC PERMIT FEE
• \Y ONE
corvE c o Jz OUTLETS-SWITCHES-RECEP 10.0011.00
LIC.rvo.
623 LIGHTING FIXTURES 10.00/1.00 ) '
CDN] T s �� PPLIANCES-RESIDENTIAL 4.00
ADDRESS ' -OZ
PHONE < PANELS 10.00
1 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
AARCH.OR DDRESS ENG SPECIALCIRCUIT 5,00 PERMI;.ygFljlON v
ZIP EMP.METER OR POLE INS. 20.00 ? JUN
APPLICANTS MOTORS SEE FEE SCH. JUN 2 Q 1JC)�
AOOREs
s N, y SERVICE CHANGE 20.00
'00 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 City of Cupertino
U w I hereby n11'irm that 1 all licensed under provisions of Chapter 9 ISSUANCE DATE
H G w (eonnnencing with Section 7000)of Divisi,,n 3 of the Rusincss and BLDG. ELECT. PLG. MECH.
r y z Protrssions Colic,and my license is in full force and effect. ❑ ❑
License Class Lic.Number
9 Z r O Dalc Contractor
, 2 a BUIL ING PERMIT
¢ rt w a OWNER-BUILDER DECLARATION IN ORMATION
o A O MISC.- REFER TO ORD ,�t�
w 3 LL y 1 for
of firm that 1 am exempt.from the Contractor's License VALUATION S/FT.
H .. O a Law for the following reason.(Sec.]031.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alteq
Qimprove,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELECCE 0 .
Ic requires the applicant for such permit to the a signed statement that TOTAL ' PERMIT TO
d w m so he is licensed pursuant to the provisions of the Contractor's License
F z r
Law(Chapter 9(commencing with Section 70000of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
Ic c the basis for the alleged exemption.Any violation of$ection 7031.5 B nu TYPE CONSTR.
ate _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollms($500).):
❑ I,as owner of the property,or my anployces with wages as BACK F LOW PROTECT. DEVICE4.00 OCC GROUP RES.UNITS
their sale compensation,will do the work,and the structure is not H
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code The Contractor's License Law does not apply to an owner of
property who builds or improves thereon..,,it who does such work FIXTURES-PER TRAP 5.00 SO.FT FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedoroffered for sale If.however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.-SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build of
in BUILDING USE
prove for purpose ofsale.). RES IND CON Pe Other
❑ I,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 ❑ Q it it
licensed contractors to construct the project(Sea 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft110.00
lire Cmumclor s License Law. TRACT NO, PARCEL NO.
❑ I an exempt under Sec. ,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'COMPF'NSA"NON DECLARAI[ON WATER TREATING EQUIP. 5.00
I hereby al Brm that I have acertificate ofconsent toself-insure. ZONING ENG.SITE NO.
or a cer 'ca of Workers'Compcnsatin nsum .pup ee{li led
ropy th r 800,Lab.C.). QUU I/!n�``
Policy Company
O ❑ C rl led ' is hereby funushed. FIRE SPRINK ENERGY T-24
Z Z ..'d y is filed w'Ih'thr y edion division. MISC.- REFER TO ORD.
F Applicant h Y ❑ N Y ❑ NC]
Cr Ii RTI ATRO EXITSIPHONP h :RS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
L COMPENSAt ION I NSURANCE: PLG.CONTR. LIC.NO. PLG.
�
Z (This section need not he Completed 11 (lie permit is for one TOTAL Y C:] N Y N❑
hundred dollars IS 100)or Icss.l
U O I Certify that in tie performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
U_ H mil is issued,I shall not employ any person in any manner so as to
O W become subject to the Worker,'Compensation Laws of California. BUILDING
a Dae Applicant ALTER OR ADD TO MECH. 5.00
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F.. Z cmption,you should become subject to lire Workeri Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT TO 109MC.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 HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's N ...0 s ELECTRIC
- Icertity that l have read this nppli,,Iiun afd stale that the above VENTI LATION FAN NG LE) 4.00
i hkoliation is correct.1 agree to comply will all city and county PLUMBING
urdinances and state laws relating to building ,n,,rudion, end BOILER-COMPI3 H.P.Or100,000B.T.U.) 6.00
hereby authorize representable, of this Cit, to enter upon lire 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 CONST.TAX
may in any way accrue against said yy consequence of the PERMIT ISSUANCE 10.00
giant i 'J❑iis permit / MECH.CONT. LIC.NO. MECH.
OTAL TOTAL
s antic 1.1 Dat
INSPECTOR COPY