The URL can be used to link to this page

C9362APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT I DENTIFICATI ON &PERMIT BUILDING - ELECTRICAL- PLUMBING - MECHANICAL - PERMIT NUMBER BUILDINGAPPLICATION DREss DDRESS A�� C OWNER'S NAME QTY. ELECTRIC PERMIT FEE PLA CHECK VALIDATION 'HONE Z NAMpRA<ORs OUTLETS -SWITCHES-RECEP 10.00/1.00 LIGHTING FIXTURES 10.00/1.00 LIC. NO. CONTRACTORSDRESs ADREs PPLIANCES- RESIDENTIAL 4.00 PANELS 10.00 PHONE DATE OF APPLICATION ARCHITECT OR ENGINEER LIC. No, PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C. NO. SIGNS TRANS. 3.00 ADDRRESS ENG. ZIP CIRCUIT 5,00 PERMIT VALIDATION PERMIT TEMP. METER OR POLE INS. 20.00 APPLICANTS ADDRESS MOTORS SEE FEE StH. SERVICE CHANGE 20.00 OY ' LICENSED CONTRACTORS DECLARATION 0.00(///'1 TEMP. POLE 30.00-LAI I hereby affirm that I am licensed under provisions of Chapin 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Class Lie Number IS DANCE DATE IDG. EL CT. PLG. MECH. Date Contractor BUILDING PERMIT INFORMATION Ii OWNER -BUILDER DECLARATION I am exempt from the Contractor's License hereby cthe ollo following Law forAncien or countywhihe.703La Permit tocodProfessions Code: Any city or county which structure permit toconsua c ,tics, improve, demolish, or repair any structure, prior n its issuance, also he is tic the applicant for such permit to file a signed statementisLithat he is Betted pursuant to the provisions of the Contractor's License Busi (Chapter 9(commencing with Section 7000) D ivision3of the and Code) or that is exempt Therefrom and MISC.- REFER TO ORD VALUATION SIFT. PERMIT ISSUANCE 10.00 ELEC. CONTR. LIG NO. TOTAL TOTAL PERMIT TO n QTV. PLUMBING PERMIT FEE STORIESTYPE CONSTR. he alleged the basis for the alleged exemption. Any violation of Section 703 the vi violation malty by any applicant fora permit subjects the applicant toacivil penalty of not Ivorc than five hundred dollars (55001.1: ALTER -DRAIN -WATER IEA.) 5.00 ❑ I, as owner of the property, or my yrapi.yee, with wages ae their sole compensation, will do the work. and the structure is not intended or offered far sale (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who days such work himself or through his own employees, provided that such improve- menuarenotintended or offered for sale. If, however. the building BgCK FLOW PROTECT. DEVICE 4.00 CCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA, COND. 5.00 FIXTURES - PER TRAP 5.00 SO. FT. FLOOR AREA TOTAL ACREAGE GAS-EA.SYSTEM-11NC.40UTLETS 6.00 or improvement is sold within one year of completion, the owner- builder will have the burden of proving that h e did not build or im- prove l or purpose nt sale.). ❑ I, as owner of the property, am exclusively contracting with - . .. GAS EASYSTEM -OVER 4 (EA) 200 BUILDING USE E IND CON PB Cine, ❑ ❑ ❑ ❑ INDUSTRIAL WASTE INTER. 30.00 licensed contractors to construct the project (Sec. 7044, Business and Professions Code The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the Contractors License Law. ❑ lam exemp(.ader ec. ,R.&P.C. for this reason LAWN SPRINKLERS - 1 INC 5 V.B. 6.00 LAWN SPRINKLERS - OVER 5 (EA.) 1.00 ASSESSORS PARCEL NO. `r SEWER -SANITARY -STORM EA. 200f1/10.00 TRACT No. PARCEL NO. WATER HEATER W/VENT 6.00 Owner Data 112A18 WATER SYSTEM 5.00 ACC.OATE ACC. FILE NO. WATER TREATING EQUIP. 5.00 .. WORK F-RS'COMPHNSAT10N Df:. AR ...... J1 IF 1 hereby affirm that I base a certificate of consent to sell -insure. or a cerlificate•of Workers' Compeiirtion Insurance, ora certified copy thereof (Sec'.'3800, Lab.C.l. ZONING ENG. SITE NO. Policy No. •Company ❑ Certified copy is hereby furnished. ❑ Certified copy is filed with the city inspection division. Appliaml FIRE SPRINK y❑ N❑ ENERGY T-24 Y'❑ N❑ MISC.- REFER TO ORD. CERI'IFICA'IEOF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.LU.O. PLG. CONTR. LIC. NO.PLO. TOTAL COMPENSATION INSURANCE (This section need not be completed if the permit is for one YE] N❑ Y❑ N❑ QTY. MECHANICAL PERMIT FEE FEE SUMMARY*' hundred dollars ($ 100) or less.) I certify that in the performance of the work for which this per- mit is issued, I shall not employ any person in any manner so as to BUILDING 119 •^�' become subject to the Workeri Compensation Laws of California. Date -Applicant 'I'O ALTER OR ADD TO MECH. 5.00 NOTICE 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 such provisions or this permit shall be devoted revoked. AIR HANDLING UNIT (TO 10=CF.M.) 4.00 FEE - AIR HANDLING UNIT(OVER I0MC.EM.) 6.00 SEISMIC FEE _ CONSTRUCT ION LENDING AGENCY I hereby affirm that there is a construction lending agency for EXHAUST HOOD -(WITH DUCT) 5.00 the 3097 performanceof the work for which this permit is issued (Sea CA MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 HEATING Lender's Name Lender's Address HEATI NG UNIT (OVER 100,000 B.T.U.)9.50 ELECTRIC I certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00 information is c(irrect. 1 agree to comply with all city and county ordinances and state laws relating to building construction, and PLUMBING BOILER-COMP13 H.P. or 100,000 B.T.U.) 6.00 BOILER -COMP (Over 100,000 BTU) SEE FEE SCI. MECHANICAL hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. MISC. - REFER TO ORD. (WI) agree to save, indemnify and keep harrnles the City of Cupertino against liabilities, judgments, costs and expenses which may in�ny way ccrue against wid yin consequence of the granting this 'mil. CONST. TAX PERMIT ISSUANCE 10.00 MECH. CONT. LIC. NO. MECH. TOTAL TOTAL Sign' ure of-ApplucantgCoAtraTlor DJI INSPECTOR COPY