9183 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT 1 DENT[FICATION PERMIT NUMBER
\/ Bu,LOINc / • - i y ai 570 APPLICATIONI& PERMIT -
/Jt, A918 3
BUILDING-ELECTRICAL-P UMBING-MECHANICAL
OwNER's - 1• PLAN CHECK VALIDATION
\ "AME - OTY. ELECTRIC PERMIT FEE
PRONE
CONTR/ 6TDR'
NAME UTLETS-SWITCHES-RECEP T 1.00
X uc.No. LIGHTING FIXTURES 1 /ADDRESS 1.00
A T APPLIANCES-RESIDENTIAL 4.00
PANELS 1000 DATE OF APPLICATION
A IUT' PLAN CHECK FEE P.O NO.
_ PANELS (OVER 200-AMP) 2000.
NGINEER
i LIC.No. SIGNS TRANS. 3.00
ARCHAR NG. PERMIT VALIDATION
ADDREss SPECIALCIRCUIT 5.00 _
AY
EMP. METER OR POLE INS. 2000. 14
-
APPLI T Y MOTORS SEE FEE$CH.
AD° ss
L4
SERVICE CHANGE 20.00 .0 fy OfCupertino-,09
oO LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 s
a Z U I hereby affirin that I am licensed under provisions of Chapter 9 ISSUANCE DATE
n ¢ (commencing with Section 7000)Of Division 3 of the Business and BLDG. ELEC P G
F m Professions Code and my license is in full force and effect ❑
z o m - License Class Lie.Number
o w- Dutc�Contractor
l a x f -J+ BUI I G P RMIT
¢
or w ¢ OWN'EIt-BUILDER DECLn Rn'1'ION IN ORMATION
OAD MISC.- REFER TO ORD
w S a -1 hereby affirm that I am exempt from the Contractor's License
ria VALUATION $/FT.
FLLoj Law for the lblluwmy reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE / 1
W Code:Any city or county which requires a permit to construct,alter, _
¢ ¢ ¢ p improve,demolish,or repair any structure,prior to its issuance.also ELEC.CONTR. LIC.NO. ELEC.
N ¢ requires the applicant for such permit to file a signed statement that "�, TOTAL PERMIT TO
A
is
m he is licensed pursuant to the provisions of the Contractors License
F Z i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe /
4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE C
¢ o the basis for the alleged exemption.Any violation of Section 7031.$ STORIES T P CONSTR.
aim by any applicant tura hundred
subjects the 0).): annoacivil punulry ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more owner
five hundred rty.o my em: ✓-
❑ I,as owner of the property,or my employees with wages asBACK FLOW PROTECT.DEVICE 4.00 OCC. R P RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sea 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply t°an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 (7` SO.FT.FLOOR AREA TOTAL ACREAGE
. mcntsl are not
hde ownemployees.for sale
If,ed ever,the
Improve.
GAS-EA.SYSTEM-1 6.00
menses are nor intended or offered Cor sale.IL ed bar s the building /
or improvement is sold within one year of completion, - . -OVER 4 IEA.) 2.00 the owner- GAS EASYSTEM
builder will have the burden of proving that he did not build or int. BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE'INTER. 30.00 E IND CON PB other
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to Innstruct the project(See 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 contractons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 n TRACT NO. PARCEL NO.
)am exempt under Sec.-,B.dP.C.to,this
reasonWATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 f_ ACC.DATE ACF FILE NO.
WORKHRS•COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to sell-insure. ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
opy Ihereof(Sea.3800,Lab.CJ. ,
Ic Nrt Company�l�
O Certified cOpy�ts hereby,fu ushe FIRE SPRINK ' ENERGY T-24
z Z -C.Zrtir'ied co y is fled w'th the city inspection division.
O_ pplicantt MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
� N ,;R I,ATT,Of F!xHMeTIO ROM WORKERS' PERMIT ISSUANCE /10.0 FLOOD ZONE A.t.u.c.
LU D COMPIi 'SATIO L SORANCL PLG.CONTR. - LIC.NO. PLG. /f� Y❑ N❑ Y C] N❑
CL o (This section need not be completed if the permit is for one TOTAL J l
0 Z hundred dollar,IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
Ow become subject to the Workeri Compensation Laws of California. BUILDING
n Onto Applicant ALTER OR ADD TO MECH. 5.00
} N NOTICE TO APPLICANT: 11,alter making this Ccnifieale of Iix-
F Z enption,you should become subject to the Workers'Compensation APPLIANCE 5.00 i,^ PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 s FEE
CONSTRUCTION LENDING AGENCY AIRHANDLING 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. '�� ICROFILM
3097,CiaC.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's NamAddie HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 • ELECTRIC
sx
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 c..my
- --. PLUMBING
ordinances and slam laws relating to building construction, and BOILER-OOMP(3 H.P.or 100.000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the r
above-mentioned property for inspection purpous. BOILER-COMP (Over 100,000 BTUI SEE FEE SCM. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino ahnst liabilities,judgments, costs and expenses whichCONST.TAX C
may in a y way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
ymntin ' Clh i"Pennit. MECH.CONT. LIC.NO. MECH. I'
G C
1;,4
TOTAL
I(/y�P �. TOTAL':
C SigyatureI Ap icant Co for Date
I ,
INSPECTOR COPY
• I