9343 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT I DENTI FICATI ON PERMIT NUMBER
im"FOING APPLICATION & PERMIT 8343
ADDRESS
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWN 'a ' - PLAN CHECK VALIDATION
NAME CITY. ELECTRIC PERMIT FEE
cq PHONE -
•I NAME ,OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.No. LIGHTING FIXTURES 10.00/1.00
R o
ADDRESS PPLIANCES-RESIDENTIAL 4.00
_
'l•- PANELS 10.00 DATE OF APPLICATION
RCHI PLAN CHECK FEE P.C.NO.
on PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADD ESS ENG. SPECIAL CIRCUIT 5.00 vERMILV A_ IpATION
ZIP EMP.METER OR POLE INS. 20.00 1P"'afAAU�tIL''R�
APPLICANTS - MOTORS SEE FEE SCH. J Ui. s 7q�I
ADDRESS
SERVICE CHANGE 20.00 JJJ
0 0 oLICENSED CONTRACTORS DECLARATION TEMP. POLE 30.00 City of Cupertino
G Li U I hereby aflinm that I am lice.wd under provisions of Chapter 9 } ISSUANCE DATE
I" (commencing with Section 7000)of Division 3 of the Business and
j m Professions Cotte,and my license is in full force and effect �t BLDG. ELECT: PLG. MECH.
z o H License Class Lie.Number ' �Q ❑ ❑ ❑
2 z 'Date ��� �Contrudor rw �'
a m
BUI NG PERMIT
¢ i[ w Q OWNER-BUILDF-R DECLARATION 1 ORMATION
st I hereby affirm that I am exempt from the Contractor.License MISC.- REFER TO ORD
VALUATION $/FT.
FLL04 Law for the following reason, 7031.5,Busincssand Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
2 ¢ 0 _improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
'� ¢ 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
HZT
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
- a Business and Professions Code)or that he is exempt therefrom unAQTY. PLUMBING PERMIT FEE
r es the basis for the alleged exemption.Any violation ofSection 7031.5 ORIF TYPE C R.
d 31° 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):
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00 OGD.GROUP RES.UNITS
their sole compensation,will do lite work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or Improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 SD.FT.FLOOR AREA TOTAL ACREAGE
himself re through his own mered for sole.provided[hat such improve
himselfcnB a throuhhisot oroempl ees.provided
that slhc building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the own . BUILDING el GAS-EASYSTEM-OVER 4 (EA.) 2.00 euILDUSE
builder will have the burden of proving that he did not build or iii /RES IND GNG PB Ouhar
Prove for purpose of sale). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with ) ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044, Business LAWN SPR INKLERS- 1 INC 5 V.B. 6-00 ASSESSOR RCEL NO.
and Professions Code:The Contractor',License Law does not apply
to an owner of properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a conlmetorls)licensed pursuant to
We Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ l am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
Felson
Owner Date WATER SYSTEM 5.00
ACG DATE ACC.FILE NO.
WORKERS'COMPBNSAT ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate of consent to self-insure. ZONING
or a certificate of Workers'Compensation Insurance,or a certifiedENG.SITE NO.
-__L- copy tlmreoffSec.3800,LOCA
O / Policy No, Company
❑ Cerlified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ CertiC copy is Illed it i the y ins a lion division.
p Applicant r citMISC.- REFER TO ORD. Y ❑ N❑ Y E) N❑
M y¢ CERTIFICA1 F.OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O (This stetimi need not be completed it the permit is for one TOTAL Y❑ NE] Y ❑ N❑
Z) Z hundred doll...1S 100)or le,,f
U O 1 certify thiit in the performance of the work for which this per OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued, I shall not cruel.,any person I,,imy mannerso as to
U become subject to the Workers Compensation Laws of California.
Lu Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE TO APPLICAN'P: If,after risking this Certificate of Ex-
Z eniption,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 deemed revoked. AIR HANDLING UNIT(TO 10,OWC.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 Address ELECTRIC
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• information is correct I agree to comply will,all city and county PLUMBING
ordinances and slate laws 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 FEESCH. 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 captures which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00 -
gmnting of this permit. l MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
� / Si na i oYAp loran/C tractor `��I am
INSPECTOR COPY