C9342 pI
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDING PROJECT IDENTIFICATION PERMIT NUMBER
BOILOING APPLICATION & PERMIT /
J ADDRESS44_14 (�
Ilxx '1 ` BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 93,42
N R ♦ 1 \ PLAN CHECK VALIDATION
NAME I, �_ - �� &Y ELECTRIC PERMIT FEE
-. n6q41 '/IFr PRONE
NAMEA TOR UTLETS-SWITCHES-RECEP 10.00/1.00
!' LIC.NO4 LIGHTING FIXTURES 10.00/1.00 W
CONTRA OR' - APPLIANCES-RESIDENTIAL 4.00
ADDRESS // '�
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.N0.
OR
ENGINEER
C✓+'IR-� LIC.NO. SIGNS TRANS: 3.00
ARCH,eSS ENC. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
�.
ZIP TEMP.METER OR POLE INS. 20.00
ARMOTORS SEE FEE SCH.
ADDDDRESSESS �J
SERVICE CHANGE ; 20.00 �^
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE - 30.00
< o U 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
,FA < w (commencing with Section 7000)of Division 3 of the Business and RLDC. ELECT. PLG. MECH.
F w z Professions Code,and my license is in full force and effect. ® ❑
2 0 - License Class Lie,Number 21
0 w H Date Contractor
a m BUILDING PERMIT
w st OWNIi R-BUILUF:R DECLARATION INFORMATION
X ;LL I hereby ul'firm Oral I am exempt (rum the Contractor's License MISC.- REFER TO ORD
�n VA)IUATION $/FT.
F u 0 j Law I.,tire lolluwing musnn.IScc.7031.5,If usincss and Professions PERMIT ISSUANCE 10.00 C/ -
,A0 Code:Any city or county which reyuiresa permit to construct,alter,
QUO
ic ea Q Q improve,demolish,or mpair any structure,prior to its issuance,also ELEC.CONTR. LIC.NOF', ELEC.
D u requires Ilia applicant bar such permit In file a signed statement that r0 TOTAL PERMIT TO
u w m lie is licensed pursuant to Ilia provisions of the Contractor's License
Hzi
Law(Chapter 9(commencing with Section 7000hif Ulvixion 3 of the
a Business and Professions Code)or that he is exempt therefrom and TV. PLUMBING PERMIT FEE �,COdf 114 R MO CIC
r 0o the basis for the alleged exemplion.Any violation of Section 7031.5 STORIES TYPE CONSTR.
i ; m by any applicant for a paniil subjects the applicant Loa civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hurdled dollars(55000.):
❑ I,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,AREA,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 S,,all work FIXTURES-PER TRAP 5.00 (^(4 SO.FT.FLOOR AREA TOTALACREAGE
• himself or through his own employees,provided dom such improve-
mlents are not intended or offered for sale.If,however,clic building GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00
Or improvement is sold within one year of completion,the owner- GASEA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
budder will have the burden of proving that he did not build or int- - REB IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with a ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code: Ilia Contractor's 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 contraclons)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the ContmclorS License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sic.-,B.&P.C.for this WATER HEATER W/VENT 6.00
reason _
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK IiRS'COMPE 'SATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.). '
Policy No. Company
O ❑ Certified copy is hereby furnished FIRESPRINK ENERGY T-24
Z Z ❑ Certified copy is fled with the city inspection division.
O Applicant MISC.- , REFER TO ORD. Y ❑ N❑ Y ❑ No
rn CERTIFICATE 01:EXEMPTIONI17RONI WO RKERS' PERMIT ISSUANCE 10.00 &(/V FLOOD ZONE A.L.U.C.
LU J COMPENSATION,INSURANCE PLG.CONTH. LIC.NO. PLG. Y❑ N F] Y E] N❑
a( This section need not he completed if the permil is for one TOTAL 'YlD
hundred doll ars 18100)or less.)
U O 1 certify that in the performance of the work for which this Per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
_ LL I- .alit is issued, I stroll not employ any person in any manner SO as to
O w beemmc subject to the Workers'Compensation Laws of California.
u Dote Applicant ALTER OR'ADD TO MECH. 5.00 BUILDING fa
} W NQIIC17 10 APPLICANT''. It,after making this Certificate of fix-
- I- Z cmptlon,you should become subject m Ilia Workers'Compcnmtion APPLIANCE 5.00 PLAN CHECK pp
Provisions of the Labor Code, you must forthwith comply with FEE //0O Z
U Sun
cll Provisios ur this Permit Shall he dcmned revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENGY-T AIR HANDLING UNIT(OVER 10)MOC.F.M.) 6.00 SEISMIC FEE 7J t
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
Lha 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 W
I certify that I have read this application and ,are
lo(Ihe shove VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county, PLUMBING
ordinances and state laws relating to building consiruaion, and BOILER-COMP(3 H.P.Dr 100,000 B.T.U.) 6.00
j • hereby authorize representatives of this city l0 enter upon Lhe
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 City in consequence of the PERMIT ISSUANCE 10.00
granting of this pCrmi6 MECH.CONT. +('.?+},LIG NO. MECH.
114 ��}�1 _ _ TOTAL TOTAL' �9 d 7
igna u Of ppfm t/Contract r' Ua c
INSPECTOR COPY
I