C9399 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
' BU LDI NG PROJECT 1 DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADORES$ 9399
2 ! BUILDING - ELECTRICAL-PLUMBING-MECHANICA
OWNER'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
® ca+ DNE
NAMeRACTOP UTLETS-SWITCHES-RECEP 10.00/1.00
c.NO 3ril LIGHTING FIXTURES 10.00/1.00
ADDDRRESSESS 's PPLIANCES-RESIDENTIAL 4.00
/ AD
-PNONE PANELS 10.00 DATE OF APPLICATION
ARCHITECTPLAN CHECK FEE �.NO.
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
7 LIC.NO. SIGNS TRANS. 3.00
SPECIAL CIRCUIT 5.00 J
AR. ENG. PER t✓�17 IDoTSNt985
ADDRESS
IIP EMP. METER OR POLE INS. 20.00
poli(CANT MOTORS SEE FEE SCH.
City Of Cupertino
SERVICE CHANGE 20.00
o w o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a u u I hereby affirm that 1 am licensed under provisions of Chapter') ISSUANCE OATS
z w (emnnumeing with Section 7000)of Division 3 of the Business anJ
,n rt y BLDG. ELECT. PLG. MECH.
F,y Professions Code and my license is in full force and efl'ec[. ❑ ❑ ❑
zo O rn -/ Lirense Class hie.Number t
z to r o Date Contractor
a m s BUILDING PERMIT
¢ 0 u u OWNER-BUILDER I am x' DECLARATION INFORMATION
w ; LL N I hereby affirm Thal I am exempt from the Contractor's License MISC.- REFER TO ORD
Loa Law for the following reason.(Sec.7031.5.Itusineesand Professions pERM1T ISSUANCE 10.00 VALUATION $/FT.
EWY� Code Any city or county which requires a permit to construct,after,
n L�
re ¢ ¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTH. LIC.NO. ELEC. V v
u iL m¢ requires the applicant for such permit to file a signed statement thin TOTAL PERMIT TO
he is licensed pursuant to tile provisions of the Contractor's License -
� zi
Law(Chapter 9(commencing with Section 7000)of Division 3 offal,
a Business and Professions Code)or that lie is exempt therefrom and QTV. PLUMBING PERMIT FEE
f ¢ a
'¢ fm UID basis for Section alleged csentpflon.Any violation Of Sccon 703LS ST IE TYPE ONSTR.
by any applicant for a permit subjectstlie applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00 r
of not more than five hundred dodarslS5001.)
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC,GROUP RES.UNITS
sole compunsalion,will do the work,olid thru
e stctuR is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Cade:The Conimcmi 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 $0.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.It,however.the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
r improvement is sold within one year of completion, the owner GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or ilii-
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 3000 RES IND CON PR Omer
0 I,as owner of the property,am exclusively contracting with .
licensed contractors to construct the project(Sec.7044,BusinessLAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code: I'he Contractor's License Law does not apply
10 an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam exempt under See. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner _ - Dam WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK(!RS'COYIPCNSATION DECLARATION WATER TREATING EQUIP, 5.00
I hereby affirm that I have u certificate of consent In sell-insure, - ZONING ENG.SITE N0.
Or a certificate of Workers'Compensation Insurance,or a certified
copy lhercof(Sec.3800,LobA).
Policy Company
O reerrtiticd copy is hereby fumishi . FIRE SPRINK' ENERGY T 24
Z 2 ❑ Cert ificopy is filed wh,h tl city linspecf n division. MISC.- REFER TO ORD.
O / Applicant V N Y N
(r
L--T PERMIT ISSUANCE 10.00 CfiRTIFIC ' YREMPTION'FROM W 'CRS' FLOOD ZONE A.L!U.C.
W CO
� COMPEPF NSATION INSURANCIPLG.CONTR. LIC.NO. PLG. t
a_ Z (This section need not be completed if the permit is for one TOTAL Y❑ N� Y ❑ N�
hundred dollar.($100)or Iris,I
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
W F mit is issued,I shall not employ any person in any manner so as to
OQbecomm subject to the Workers'Compensation Laws of California.
ELI
D- Dat° Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>_ to NOTICE '1'O APPLIC'AN I': IL-after making this Certificate of E.
F Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must I-orthwit h comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT ITO 10=C.F.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10SWOF.M.) 6.00 SEISMIC FEEE'''1y,5
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.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UN IT 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address '
I certify that l have read this application and state that tire above VENTILATION FAN (SINGLE)t 4.00 I.
•ri information is correct. I agree to comply with all city and county PLUMBING
t ordinances and state 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 tike
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 CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
grantinn this permit MECH.CONT. LIC.NO. MECH. r
TOTAL
TOTAL /
Signat eo Co aclo a Gh
INSPECTOR COPY
r �