9022 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
PERMIT NUMBER
BUILDING APPLICATION & PERMIT 7 fy'� n/ (/�
aoones;•�f,O��i /��F/�J /` V 0 LJ 2 BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME ) QTY. ELECTRIC PERMIT FEE
�,J/�/'/��S• O PHONE �ft&r
CONTRACTORS ry OUTLETS-SWITCHES-RECEP 10.00/1.00
C� �7N�' uc.No 31J� '� LIGHTING FIXTURES 10.00/1.00
CONTRACTORSa2Tr v APPLIANCES-RESIDENTIAL 4.00
//W
PANELS 10,D0 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5.00 _PM$ItW1LIGATION
ZIP TEMP.METER OR POLE INS. 20.00
nitro ess S MOTORS SEE FEE SCH MAY G -
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 City of Cupertino
Quo I hereby affirm that I am licensed under provisions of Chapter 9 i r
w a N commencing with Section 70001 of Division 3 of the Business and ISSUAN DATE
/ BLDG. EL CT PLG. MECH.
v,w z Professions Cod 2 an my license is in full for yllYeHel�1 ❑ ❑ ❑
z i m- License Class V Lic.Number G f'lo
O Date Contractor
Q y E J
E E w.a cr-
OWNER-B UILDF:R DECLARATION BU DING PERMIT
E o a NFORMATION
X 3 0 y I hereby affirm that 1 am exempt from tile Contractor's License MISC.- REFER TO ORD
u O v, Law for the following reason.(Sec.7031.5,Business and Professions VALUATION $/FT.
- PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
al Q Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
o¢ requires the applicant for such permit to file a signed statement that TOTAL MIT TO
e tam he is licensed pursuant to the provisions of the Contractor's License
H z a
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe r
f 4 D Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
E H o the basis for the alleged exemption.Any violation of Section 7031.5
by any applicant for a permit subjects the applicant toa civil penalty BTO ES TYPE CONSTR.
of not more than five hundred dollars($500).): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ I,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:Tim Contractors License Law does not apply to an owner of
•
property who buildsimproves thereon,vwho does such work FIXTURES-PER TRAP 5.06 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through hisis own employees,provided that such improve-
mentsarenotintended Or Offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or inI- BUILDING E
prove for purpose ofsalcJ. INDUSTRIAL WASTE INTER. 30.00 RES E] El o O
m D
❑ I,as owner of the property,aexclusively contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSEg50 RCEL N0.
and Professions Code:The Contractor's License Law does nor 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 contractorts)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10,00 TRACT N PARCEL NO.
❑ lam exempt under S"...B.&P.C.for this
reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE N0.
WORK ERS'COMPENSATION UCLA RATION WATER TREATING EQUIP. 5.00
1 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.
C of(Sec.3800,Lab.C.).
olicy No. Company
O ❑ Certi led copy is hereby furnished.
Z Z ❑ Celli ied copy is fled with the city inspection division. FIRE SPRINK ENERGY T.Z4
FO Applicant MISC.- REFER TO ORD. Y � NE3 v � N�
LUy ERTIFICA11i OP EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 PLOODZONE A.L.UF.
W - COMPIiNSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL ❑ 11 his auction need not be completed if the permit is for one TOTAL v N V N
Z hundred dollars IS 100)or less.)
L) O• 1 terrify that in the performance of the work for which this per- EAIR
MECHANICAL PERMIT FEE FEE SUMMARY
LL H mil is issue ,I Shall ,not employ apyp peryl .in any I mnner so us to
U .hecoln c/Lf �rs'(.X/d a/m6 n Calilbrniu.
y Date A1Sp1 OR ADD TO MECH. 5.00 BUILDING
} to NOTIC T AN CANT' , iter making this Certificate of Ex-
(_ Z emotion,you should ecome s jeer to the Workers'CompensationNCE 5.00 PLAN CHECK
U such provisionsvisions of lhe or rhisbor permi aha I be deemed re you oil evoked comply withDLING UNIT(TO 10;=C.F.M) 4.00 FEE
CONSTRUCTION LENDING'AGENCY DLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency forST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec.
3097,Civ.C.l. - HEATING UNIT IT0100,000 B.T.U.) 6.00 MICROFILM
Lender's Name
Lende'r's Address HEATING UNIT(OVER 100,000
BE TU)
9.50 ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• information is correct. I agree to comply with all city and county PLUMBING
ordin.eces and .state laws relating to building construction. and BOILER-ODMP(3 H.P.or 100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree m 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
gran tin�� this r if MECH.CONT. LIG NO. MECH.
S ( � TOTAL TOTAL
Sign re of pplicam/Contractor Date
OFFICE COPY