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ANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLYWLU71_'LDl NG PROJECT ! DEN7F1CATION
PERMIT NUMBER
BIIILO NG
APPLICATION & PERMIT
09527ADDRESS
BUILDING — ELECTRICAL— PLUMBING — MECHANICAL
OWNG111" ,'PLAN CHECKVALIDATION
NAME QTY.ELECTRIC PERMIT FEE
CCINTAACT R UTLETS-SWITCHES-RECEP 10.0011.00TNAE
ND. LIGHTING FIXTURES 10.0011,00
DDRES CTOASADDRESS PPLIANCES- RESIDENTIAL 4.00
IQ) 60
A
PHONE a&l PANELS 10,00 DATE OF APPLICATION
ARCHITECT
PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE
OR
P,C.NO.
ENGINEER
uc. NO. SIGNS TRANS, 3.00
ARCH. OR ENG' SPECIAL CIRCUIT 5,00 PEgMliflJpl>f
JION
ZIP EMP. METER OR POLE INS, 20.00
E!"ll
APPLICANT'S
ADDRESS
MOTORS SEE FEE SCH. AUG 231985
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION TEMP, POLE 30.00 City of Cupertino
1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
commencing with Section 7000) of Division 3 of the Business and BLDG. ELECT. L MECH,
Professions Co an license is in full force n eftc
License CI Lic. NumberEl El El
Dote Contractor
OWNER -BUILDER DECLARATION
BUILDING PERMIT
I hereby affirm that I am exempt from the Contractor's License MISC. — REFER TO ORD
INFORMA .ION
VALUATION SIFT. Law for the following reason, (Sec. 7031.5, Business and Professions PERMIT ISSUANCE 10.00
Code: Any city or county which requires a permit to construct, alter,
improve, demolish, or repair any structure, prior to its issuance, also ELEC. CONTH. 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
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
the basis for the alleged exemption. Any violation of Section 703 1.5 STOFfES TYPECONSTR-
by any applicant for a permit subjects the applicant to civil penalty ALTER -DRAIN &VENT -WATER {EA.) 5.00ofnotmorethanfivehundreddollars (5500).):
1, as owner of the property, or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation, will do the work, and the structure is not OCC. GROUP RES. UNITS
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
propertywho buildsorimproves thereon, and who does such work FIXTURES - PER TRAP 5.00 SQFT,FLOOR AREA TOTALACREAGE
himself or through bis own employees, provided that such improve-
mes are not intended or offered for sale. If, however, the building GAS - EA. SYSTEM -1 I N C.4 OUTLETS 6,00mIn
or improvement is sold within one year of completion, the owner-
GAS - EA. SYSTEM -OVER 4 {EA.) 2,00 8I11LDING USEbuilderwillhavetheburdenofprovingthathedidnotbuildorim-
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30,00
E IND COSY PB Other
111, 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 X ASSESSORS PARCEL NO.
and Professions Code: The Contractor's License Law does not apply
to 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,ODtheContractor's License Law. T0 TRACT NO. PARCEL NO.
am exempt under Sec. 114P.C. for this WATER HEATER WIV ENT 6.00 G dreason
Owner Date WATER SYSTEM 5.00 ACC. DATE ACC. FILE NO.
WORKERS' COMPENSATION DECLARATION WATER TREATING EQUIP. 5,00
hereby affirm that I have a certificate of consent to self -insure,
or a certificate of Workers' Compensation Insurance, or a certified ZONING ENG. SITE NO.
copy thereof (Sec. 3800, Lab.C.).
Policy No. Company
El Certified copy is hereby furnished. FIRE SPRINK ENERGY T•24
Certified y is filed with city inspection division.
App ant &0 . TIG /Z MISC. - REFER TO ORD, y N y N
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10,00 O FLOOD ZONE A.L,u.c.
COMPENSATION INSURANCE PLG. CONTR. LIC. NO, PLG, 00
This section need not be completed if the permit is for one TOTAL Y N Y N
hundred dollars (S 100) or less.)
1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
mil is issued, I shall not employ any person in any manner so as to
become subject to the Workers' Compensation Laws of California.
Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
NOTICE TO APPLICANT; If, after making this Certificate of Ex-
emption• you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEEsuchprovisionsorthispermitshallbedeemedrevoked, AIR HANDLING UNIT ATO 10MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT (OVER 10MOC.F,M.) 6.00 SEISMIC FEE
hereby affirm that there is a construction tending 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.)9.50Lender's Address ,.. ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city and county PLUMBING CO
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 the BOILER -COMP (Over 100.000 BTU) SEE FEE SCH. MECHANICALabove-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
PERMIT ISSUANCE 14.00
CONST. TAX
may in any w accrue against said City in consequence of the
gran,g thi ermit. / MECH. CONT: LIC. NO. MECH.
TOTAL
TOTAL
Sigma urc of Applicant/Contractor Date
OFFICE COPYOFFICE COPY