C9205 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PE ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT ^��
r ADDRESS
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 9205
Ily
IN 1IR N PLAN CHECK VALIDATIO
WN
"AM . Iw f t 15 N T ELECTRIC PERMIT FEE -
•
ONE
NAM ACD s // OUTLETS-SWITCHES-RECEP 10.00/1.00
+: i I �"✓
LIC,NO LIGHTING FIXTURES 10.00/1.00
OGRE GroRs
ASS PPLIANCES-RESIDENTIAL 4.00
CONTRA
' PHONE PANELS 10.00 DATE OF APPLICATION
` ARCHITECT PLAN CHECK FEE P.C.NO,
OR PANELS (OVER 200 AMP) 20.00
NGINEER
_
LIC,NO SIGNS TRANS. 3.00
...HESS E"G SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 s
wO o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
rt u p I hereby affirm that 1 um licensed under provisions of Chapter 9 ISSUANCE DATE
n (amuncrong with Section 7000)of Division 3 of the Business and 4 wBLDG. ELECT. PLG. MECH. !
h, �i Professions Code,and my license Is in full force and effect.
z 0 e - License Class Lia Number
O m F Dote Contractor
y fBUILDING PERMIT
Qw OWNER-BUILDER DECLARATION INFORMATION
3
w ,a o n H 1 herefiram exempt by affirm that I t from theonra
Contractor's License MISC.- REFER TO ORD
u VALUATION $/FT.
FLL0 < Law for the following reason.(Sec.7031.5.Business Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct alter
K ¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. 19q v)n
a m M requires the applicant for such permit to file a signed statement that TOTAL E IT TO
n w 1e is licensed pursuant to the provisions mf the Contractor's License
r i i
Law(Chapter 9lcomntcncingwith Section 7000)ol'Division 3 ofthe
a Business and Professions Code)or that he is cxenlpl therefrom mW QTY. PLUMBING PERMIT FEE
I 0 the basis for the alleged excanption.Any violation of SccUon7031.5 TORI TVP
d '; � by any applicant for a permit subjects the applicant toacivil penalty ALTER-DRAIN -WATER (Eq) 5.00
of not more than five hundred dollars(5500).): . -
O 1,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,AR EA,COND. 5.04
Code: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 s0.FT.FLOOR AREA TOTAL ACREAGE
(himself or through his own employees.provided that such iin,mve-
t tnents are rat intended or offered for sale If,however,the building GAS-EA.SYSTEM-l1NC.40UTLETS 6.00
i or improvement Is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING E
builder will have the burden of proving that he did not build or ire RES IN. C PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. _30.00
gy�pp'' I,as owner ol'the property,am exclusively contracting with ❑ ❑ ❑ ❑
IitElised contractors to construct the project(Sec 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSo P CEL NO.
sad 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 e
contracts forsuch projectswith a contractorts)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. - TRACT NO, PARCEL.NO:,
❑ lam exempt under Seca ,B.&P.C.tbrthis WATER HEATER W/VENT 6.00
rayon
Own'` Date g WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
L. 'O RKERS'COM PENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate of consent to self-insure.
t or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE N0.
copy thereof(Sec 3800,Lab.C.).
Policy No. Company
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T2
Z Z ❑ Certified copy is Bled with the city inspecliom division.
FO Applicant MISC.- REFER TO ORD, y,❑ N❑ Y ❑ N❑
m PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.0 c.
- CERTIIICA'I'li OI'EXEMPTION FROM WORKIiRS'
W > COMIPENSA"PION INSURANCE PLO.CONTR. LIC.NO. PLG. Y[:] N❑ V C] N❑
CL O ('Phis 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 performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mil is issued,I shall not ensploy any person in:my manner so as to
U w become subject to the Workers'Compensation Laws of California.
ED Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING 50
} to NOTICE TO APPLICAN"I': If,after making this Certificate of Ex- '
F Z emption,you should become subject to the WorkerF Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U Buell provisions or t11is permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MOQF.M.) 6.00 SEISMIC FEEb�
1 ,2
I hereby affirm that there is-'a construction°loading agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Cie.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)Lender's Address ELECTRIC
I certify that I have read this application and state That the above VENTILATION FAN (SINGLE) 4.00
a information is correct.1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to huilding 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
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify 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 way accrue against said City in consequence of the
granting of[his permit MECH.CONE LIC.NO. MECH. I
\ - OTAL TOTAL 3
/\\ lure o 'p llUMMTRCtOr l4re 1 -
INSPECTOR COPY
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