C09602 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT 1 DENTI FICATI ON PERMIT NUMBER
BmLDING APPLICATION & PERMIT
ADDRESS o(�c n
IJ4i Z WJLIC RD BUILDING-ELECTRICAL-PLUMBING-MECHANICAL X96 G
OWNER'S
NAME PLA HECK VALIDATION
• 12� Y fL ) C' Ob 06 QTY' ELECTRIC PERMIT FEE
PRO E
�- NAME� Acrogs TLE
TS
-SWITCHES-RECEP 10.00/1.0070-
Ok.i�41C_ cJ N7. . C = '.0 ?0 ��b LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
ADDRESS " \ PPLIANCES-RESIDENTIAL 4.00
34-(Y t l r} VI AML PANELS 10.00
GATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.No. SIGNS TRANS. 3.00 ,4 Ilia
ARCH.ESS eec. - SPECIAL CIRCUIT 5.00 PER MI L TION
ZIP EMP.METER OR POLE INS. 20.00
ADDRESS ANTS
!_ MOTORS SEE FEE SCH. ��� o � ����
SERVICECHANGE 20.00of Cupertino
o a LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 C11Y,
G U u 1 hereby affnn that I am licensed under pmvisions of Chapter 9 ISSUANCE DATE
m ¢H (commencing with Section]000)of Division 3 of the Rosiness and - BLDG ELEC PLG. MECH.
H w z Professions Code and my license is in full force and effect. ❑ El 0 moo I-icense Class (� Lic.Number _
'D'etc Contract.(
a w a OWNER-BUILDER DECLARATION U DING PERMIT
°' ° MISC.- REFER TO ORD INFORMATION
E:
; LL ti I hereby affirm th:d I am exempr from the Contractor's License
HLoa Law for lire following reason.(Sec.7031.5.13usiness'and Professions PERMIT ISSUANCEVALUATION $/FT.
wr Code:Amycityorcounty which requires a permit to construct,alter. 10.00 <
a improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
°LL requires the applicant for such permit to file a signed statement that TOTALaO
e w m he is h"InSUd pursuant to the Provisions of the Contractor's License PERMIT TO
R z i
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
F 4 o Rosiness and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
iSby any applicant lot a permit subjccls the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500T)
❑ 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(Sea 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Core:'Fire Contractor's License Law does not apply to an owner of
property who builds VI improves thereon,and who docs well Work F IXTUR ES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedoroffered for sale.If.however,the building GAS-EA.SYSTEM-11NC.4 OUTLETS,6.00
or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
prove for purpose of the
INDUSTRIAL WASTE INTER. 30.00 RES IND D Q Dr❑ner
❑ L as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044, Business LAWN SPRINKLERS- 1 INC 5 V.B. \6.00 ASSESSO RCEL NO.
and Professions Code:The Contract.,',License s therces not apply
co an owner of property ec who builds tr improves used uand who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts ct such License
L with a contractorfs)licensed pursuant to
the Col in exempt
License Law. SEWER-SAN ITAR V-STORM EA.200ft/10.00 TRACT NO PARCEL NO.
❑ tum Oxcmpt under See_,B.&P.C.for this
Owner WATER HEATER W/VENT 6.00
Owner Date WATER_SYSTEM5.00 ACC.DATE ACC.FILE NO.
WORK I.RS'COMPBNSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certilscale of,ons'ent In selGinsure.
or a certificate of Workers'Compensation Insurance,or w certified ZONING, ENG.SITE NO.
copy thereof(Sce.3800,Lab.C.).
Policy No. Company CTl (e'h Gl v '
O ❑ Certified copy is hereby funishcd. RE SPRINK ENERGY T-24
'z Z ❑ Certified copy is fled we Y inspection division.
Applicant ylb Hh (P. MISC.- REFER TO ORD. ry N v N
M N CFRT'IFIGC['E OP EXEMPTION FROM WORKERSPERMIT ISSUANCE 10.00 ` FLOOD ZONE A.L.U.c.
LU > COhIPE.NSA1'ION INSURANCE PLO.CONTR. LIC.NO. PLG.
0- D (This section need not be completed if the permit is for one TOTAL Y E] N[]N❑ Y N
Z hundred dollars(5100)or less.)
U O I certify that in the performance of the work for which this per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL I- Init is Ixalled,I shall not employ any parson in any manner so as to
U become subject to the Workers Compensation Laws of California.
0. Dore Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex-
♦- Z emption,'you Should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with U FEE such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction Inuring agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.T HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATI NG UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and statrihat I]m above 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 construction. and BOILER-COMP(3 H.P.or100,000B.T.U.) 6.00
hereby JLienthoriiu representatives of this city 1. corer upon the BOILER-COMP (Over 100,000 STU)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 Penoil. MECH.CONT. LIC.NO. MECH.
/�p�p��J/� TOTAL
�- Stgnatureu' FAppllcant/lAir rD - TOTAL
INSPECTOR COPY