09652 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
i BUILDING APPLICATION & PERMIT
a AODA€ssl RCCI .I� i11Y BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 09652
OWN M' �7V �VW PLAN CHECK VALIDATION
. ry M u ) ONE -IStD '
1r WN �U CITY. ELECTRIC PERMIT FEE
I PHONE
CONTRAc7OR S n
NAME/If Y'Q,Y IO'CIVt rl'f( ��flClltldnlnr7 CGG'l^^IV Of UTLETS!SWITCHES-RECEP 10.00/1.00
KI VpG - LIC.No 9 .A./ LIGHTING FIXTURES 10.00/1.00
r-oNTRAcioRs PPLIANCES-RESIDENTIAL 4.00
ADDRESS L & 10P,d
CYIO IY'On Sr,��[[JJ PXONE PANELS 10.00
DATE OF APPLICATION
ARCHITECTPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO. n
ENGINEER
uc.NO, SIGNS TRANS. 3.00
AARCH.OR
DDRESS ENG SPECIALCIRCUIT 5,00 �' P59t•Y1"IDATION'
ZIP EMP.METER OR POLE INS. 20.00 �� &L
APPLICANTS
ADDRESS SEP
MOTORS SEE FEE SCH. SEe 9 1�NIJ
SERVICE CHANGE 20.00
w O o LICENSED CON'TRACI'ORT DECLARATION TEMP.POLE 30.00 ' Q{ Weff11111
Q u I hereby affirm that I am licensed under provisions of 0rapler 9 ISSUANCE DATE
v,z i (commencing with Section 7000)of Division 3 of the Business and
Z BLDG. ELECT. PLG. MECH.
F w i Professions Code,and my license is in full force and effect. ❑ ❑
z o m - License Class --�Lic.Number
p:so e,
N Date Contractor in
st sa 4 BUILDING PERMIT/
¢ ¢ ¢ OWNER-BUILDER DECLARATION
o d u INFORMATION
X ; I hereby affirm that I ton exempt Ironh the Contractor's License MISC.- _ REFER TO ORD VALUATION
.. O a Law for the following reason.(Sce.7031.5,Businessand Professions S/FT.
+_ PERMIT ISSUANCE "� 10.00
i4 improve,
Any direr county whiny structure permit toconst construct, lltq
¢ Qha improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. UC.N0. ELEC.
u w m,LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License
H ae i� Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a 'Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE -�
¢ F o thclbasis for the alleged exemption.Any violation of Section 703 LS STORIES TYPE CONSTR.
s3 � byanyapplicant for a permit subjects the applicant ton civil penalty gLTER-DRAIN& VENT-WATER (EA.) 5.00 1
of not more than five hundred dollars(55000.):
❑ 1,as owner of Ibt 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 to, sale (Sec. 7044, Business mrd Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Cnde:The Contractor's License Law does not 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
._. hinuellor through his own employees,provided that such impruvs.
ments are not intended or offered for sale.If,however.the building GAS-EA.SYSTEM-11NC.40UTLETS 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 or int- BUI NG E
prove for purpose ofsali.). INDUSTRIAL WASTE INTER. 30.00 RES IND o PB other
13 "L as owner of the property,am exclusively contracting with ❑ ❑ ❑
licensed contraei'ors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESR CEL NO.
and Professions Code:The Contractor s License Law deep not apply
to an owner of property who builds or improves thereon.and who LAWN SPR IN KLERS-OVER 5 (EA.) 1,00
contracts for such projects with u contractors)1iLcRSed'ptdral1u d In
the Contractor's License Luw, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO. i
❑ I am exempt under Stt. ,B.&I{(.fur this WATER HEATER W(VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE - ACC.FILE NO,
WORKERS'LMPI'NSA'FION 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 the, Rf(Sec. 80 Lab C.).�/� � '
Policy N 'y�y
O ❑ Certified op, CbRf ish FIRE SPRINK h ENERGY T 24
Z 2 Certified rl-Ifwith t • 'nspection division. MISC.- REFER TO ORD..O AA want Y O N❑ V ❑ N❑
~ in V PERMIT ISSUANCE 10.00 PLooO ZONE A.L.u.c.
E 1- °E%EMPITON PROM WORKERS' IL).VV
W COMPI'.NSA'LION INSURANCE Nil; y py. - L 44 NO. PLG.
Q. a 1' his wclionah ee l ooh be completed if the permit is for one Y TOTAL ��� V❑ No Y ❑ N❑
hundred dollars IS
100)or IussJ'
U O 1 certify that in the performance of the work for which this per- OTV. MECHANICAL PERMIT FEE FEE SUMMARY
U_ f- mit is issued, I shall not employ any person in any manner so as to ,
U w become subject to the Workers'Compensation Laws of California.
u Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F Z eruption,you should become subject to the Workers'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 deenhnd revoked. AIR HANDLING UNIT(TO 10)"C.F.M.) 4.00
CONST'RUC3'ION LFNDING'AGENCV AIR HANDLING UNIT(OVER 10,000C.RM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5,00
tire 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 Address ELECTRIC
I certify that I have read this application and state(hatthe above VENTILATION FAN (SINGLE) 4.00
® information is correct. I agree to comply with all city and county g01LER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING �O
ordinances and stat.laws relating to building construe lion, and
hereby enthorim representativesofThis city u enmr 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 harmlrss the City of MISC.- REFER TO ORD.
Cupertino against liabilities,jh gmenU, costs and expenses which PERMIT ISSUANCE 10.00 O Q� CONST.TAX
may in eny ay a rue a• tat said Ci y in consequene of the
c
yrantingo' t it. ' xxECK CONT. LIC.NO. MECH,�J TIVIQvhQn fTb furcL�u '^� d' F r F TOTAL TOTAL
h• to A Date N, ipmNer )'Ic ". rw
INSPECTORCOPT-. '