9337 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FI CATION PERMIT NUMBER
BUILDING
oocis APPLICATION & PERMIT r
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL Mt.
OwNE 'S _ PLAN CHECK VALIDATION
7 NAME r OTY. ELECTRIC PERMIT FEE
.�
PHONE
/� HAMR UTLETS-SWITCHES-RECEP 10.00/1.00
/ LIG.NO. LIGHTING FIXTURES 10.00/1.00
a oR's
ADDRESS PPLIANCES-RESIDENTIAL 4.00
a D
d4 0ONE PANELS 10.00 DATED P ION
OR
PANELS (OVER 200 AMP) 20.00 PLAN CHECK P.C.NO.
ENGINEER
uc,No, SIGNS TRANS. 3.00 I _
ADD ENC. SPECIAL CIRCUIT 5,00 PERMIT V LIQA O
ZIP TEMP.METER OR POLE INS. 20.00 city Of
APPLICANT'S MOTORS SEE FEE SCH, Cupertino
ADDRESS
SERVICE CHANGE 20.00
00 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a cs I hereby ul'Gnn that I urn licensed undeI......wons of Chapter 9 ISSUANCE DA
lcommencing with Section 7000)of Division 3 of the Business and
i BLDG. ELECT. P MECH.
F w i I'mfessions Code,and my license is in full force and effect. ❑
Z
0 w License Class_�3,..�Lic.Number ❑ ❑ LN
F w H J
Date Contractor
a y fL�- BUILDING P RMIT
c 0 u
OWNER-BUILDER DIiCLA RATI INFORM ION
K
; W y 1 hereby affirni that 1 ain exempt from the Contractor's License MISC.- REFER TO ORD vALuanON
Fu Oa Law for the lollowing reason.(Sec.7031.5.licsinessund FoAcssions
PERMIT ISSUANCE 10.00 $/FT.
Codc:Any city or county which requires a pcnnit to LronstmcL ultra
p { y prior to its issuance,also ELEC.CONTR. LIC.N0.
a
improve,demolish,or repair an structure,I ELEC.
a wO LL squires the applicant for such permit to file a signed slatemrnt that TOTAL PERMITTO
m w he is licensed pursuant to the provisions of the Contractor's License
F z rt
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ H D the basis for the alleged exemption.Any vlolallon Of Section 7031.5 i STO IfS YPE CONSTR..
u ; � by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than live hundred dollars($500).):
❑ 1,as owner of the property,or my employees with wages;is BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensluion,will do the work,and the strueUne is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Cade:The Contractor's License Law docs not apply to an owner of
property who builds or improves thereon,and who does such work A FIXTURES-PER TRAP 5.00 so.FT FLDOR AREA TOTALACREAGE
-• himself or through his own employees,provided that such improve- F -
HunlsamNotinlendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, the owner. GAS EASYSTEM OVER 4(EA.) 200
builder will have the burden of proving that h - . - . .
e did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 s IND CON Pa Omer
D 1,as owner of the property,um exclusively contracting with . .
❑ ❑ ❑ ❑
hLerwed contractors to construct the project(See. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 AssESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or imploves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contra-16ds1 licensed pursuant to SEWER-SANITARY-STORM EA.2001t/10.00
lire Contractors License Law. V,y TRACT NO. PARCEL NO.
O lam exempt under Sea .114P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACG FILE NO.
„R. ... WORKIiCONPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby off teff that I have a certificate ol'cunsnit to self-insure, 20NING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sec 3800,I-ah.C.1.
Policy No. Company
Certified _
Q ❑ Cered copy is hereby famished FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O , Applicant Y E] N❑ Y E] NE]
va PERMIT ISSUANCE 10.00
LU - CERTIFICA'11S OF EXEMPTION FROh1 WORKERS' FLOOD ZONE A.L.0 c.
W > COMPCNSATION INSURANCE: PLG.CONTR. LIC.No. IPLG, I
CLC)CL Z I I'[iis section need not be completed it the permit is for one Tfi141L Y E] N❑ Y[:] N❑
hundred dollars IS 100)or Icss.)
U O 1 certify that in the performance of the work liter which this per CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in any nl ander so as Io
U L) become subject to they'..kers'Compensation Lawx of California.
a DateIplicanl /^ ALTER OR ADD TO MECH. 5.00 BUILDING
} y NOTI \P 1 AN1': II ft r ma'Ing i. m cote o i
2 cmption,you should become subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you nest forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10)000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000QEM.) 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(See. MICROFILM
3097,Civ.C.k HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.19.50
Lender's Address ELECTRIC
I certify that l have read this application and state that the above V ENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city anJ county PLUMBING
ordinances and state laws relating to building construction• and BOILER-COMP(3 H.P.or 100,0006.T.U.) 6.00
hereby authorize representatives of this city to inter upon the BOILER-COMP (Over 100,OOGBTUISEE FEESCH. MECHANICAL
ubovc-mentioned property for inspection purposes,
(We) agree m save, indemnify and keep harmless circ City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which pERMIT ISSUANCE 10.00 CONST.TAX
se9
may in any way accrue against said City in conmence of lire
gmetingoflhis permit. MECH.CONT. LIC.NO. MECH.
TOTAL 6r TOTAL
CSi nlNr_o a on ra ate '
INSPECTOR COPY
i I