9301 F
APPLICANT TO FILL IN INFORMATION WITHIN RED LINE!-'-�.
VSE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION . PERMIT NUMBER
BD LDIN APPLICATION & PERMIT 9301�O
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL `�
_09
wN H'B PLAN CHECK VALIDATION
NAME CITY. ELECTRIC PERMIT FEE
` PHONE
AME AMMINTERAcio 's OUTLETS-SWITCHES-RECEP 10.00/1.00
uc.No. 0.)LjrLIGHTING FIXTURES 10.00/1.00
ADDRESSDTRA offs PPLIANCES-RESIDENTIAL 4.00
A
A/LPNONE 746.090 PANELS 10.00 DATE OF APPLICATION
ARRCHITECi PANELS IOVER 200 AMPI 20.00 PLAN CHECKFEET.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ADDRESS ENL. SPECIAL CIRCUIT 5,00 PERM ION
ZIP EMP.METER OR POLE INS. 20,00 JUL 1 G 1585
ADDRESS
APPLICANTS - MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 City Of CUpBtfInO
¢z w I hereby affirm that I am licensed under provisions of Chapter 9 �� ISSUANCE DATE
tj ¢ a (Commencing with Section 7000)of Division 3 of the Business and BLDG. LE T. PLG. MECH.
H G i Professions CoA nd my license is in full fo ¢f(CgL / ❑ ❑ ❑
2 0 License,�jass Llc.Nwnber rl1(]___i�hgj-.
9 y r w Dale_/_I_ Cont radar �
a x �-Z �- I BUILDING PERMIT
rc ¢ OWNER-BUILDER DECLARATION
E o a O INFORMATION
R
0 w 1 hereby affirm IIIat I am exempt from the Contracmr's License MISC.- REFER TO ORD
VALUATION
r,c 0j Law for the following reason.lSec.7031.5,BusinessanA Professions PERMIT ISSUANCE 10.00
my Code:Any city or county which requiresa permit toconslruct,alter,
re ¢ a 20 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
to
D¢ requires the applicant for such permit to file a signed statement that TOTAL
e w $m he is licensed pursuant to the provisions Cut the Contractors License PERMIT TO
r Law(Chapter 9(comment,mgwilh Section 7000)of Division 3 ofthe
E i o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
2 H$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
n 3 .- by any applicant for a permit subjects the applicant too civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars($500).1:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves Ihereon,and who does such work FIXTURES-PER TRAP 5.00 SG.FT.FLOOR AREA TOTAL ACREAGE
• himself re through his own employees,provided that such improve-
or nts improvemenotnt is sold or within ed one or year e.o(roto ever,teflon thebuildingowner, GAS-EA.SYSTEM-1 1NC.4 OUTLETS 6,00
or improvement is sold within one year of he did ion,the owner GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove pner of sale.). INDUSTRIAL WASTE INTER3000 IND CON PB Dram
1.as owner wner of the property,am exclusively contracting with . ,
❑ ❑ ❑ ❑
licensed
as o
cantrs Cede;
to rconstructe Ccurtm the project La 7044,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Cade:The Contractor's License s thereon.
does
eon not apply
to tr owner of property who builds r improves Thereon.and who LAWN SPRINKLERS•OVER$(EA.) 1.00
contracts for such cenjecL with n cnntrucmrtsl licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.Inr this
reason WATER HEATER WIVENT 6.00 .
Owner Date WATER SYSTEM 5.00
ACC.GATE ACC.FILE N0.
WORK ERS'COMPENSA'rION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofennsent to self-insure, ZONING or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No.-Company-
0
ompany0 ❑ Certified copy is hereby to ')led. FIRE SPANK ENERGY T-24
Z 2 )( Ceryy((''le copy is Fsled wi he city inspection division. ❑ ❑ ❑ ❑
p O All...2fl_C t. brie MISC.• REFER TO ORD. y N Y N
00
LU to CIiRTIPICOF ER
PTIO OMWORKF.RS' PERMIT ISSUANCE 10. FLOODZONE A.L.u.C.
W COM� COMPENENSATWION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL Z( This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ No
hundred dollars IS 100)or less.)
U O I certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in any manner So its to
O W become subject to the Workers'Compensation laws of California.
Is. Date Applicant ALTER OR AOD TO MECH. 5.00 BUILDING
} m NOTICE TO APPLICANT: If,after making this Certificate of Ex-
L.. 2 on ption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
Provisions of the Labor Code, you mus[ forthwith comply with FEE
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 1000011F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10MC.F.M.) 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(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.)9.50
Lenders Address ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information correct I agree tPLUMBING
ordinances and state laws relating to building construction, and BOILER-ODMP(3 H.P.Or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
aBOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree In save, indemnify and keep harmless the City of ' ill REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
*S,01'Ria
nywayaccrueagoras, sal, City10 consequence of thefIispermitMECH.CONT. LIC.NO. MECH.
TOTALTOTAL
of Applicant/Con for Ualc
OFFICE COPY