09647 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
L BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
aOGRESS
' L /V/
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 09647
OWNERS
PLAN CHECK VALIDATION
NAME / QTY. ELECTRIC PERMIT FEE
ONE
CNAME ONTRACTORS IOUTLETS-SWITCHES-RECEP 10.00/1.00 �Q
LIONO. i/ LIGHTING FIXTURES 10.00/1.00
ADDDRESSDRESS
ATOHs APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ORCH E PANELS (OVER 200 AMP) 20.00 - PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS END' SPECIAL CIRCUIT 5.00 PER TION
ZIP EMP.METER OR POLE INS. 20.00 AUGry q gE
APPLICANT
DDDRESS Ts MOTORS SEE FEE SCH. n G 2 U I�aO
SERVICE CHANGE 20.00
,00
0o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 City Of Cupe(fln0
SEE i w I hereby uffirnh that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
a a (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
o
F i Professions Co ay(�my license is in full force and of cl. ❑ ❑ 1:1z o y - License Clan(f_!�Lic.Numbcry " T
E,y F w Dale �. Contractor
a Y E BUI{. ING PERMIT
m a OWNER-BUILDER DECLARATION
E o a u INFORMATION
X
I hereby affirm that 1 .,it exempt from the Qmtrucmi s License MISC.- REFER TO ORD
LL o¢ Law for the following reason.(Sec.7031.5,Business and Professions
VALUATION $/FT.
- 0 � Code:Any city or county which requires a permit to construct.alter, PERMIT ISSUANCE 10.00 i
Qa Q Q Improve,demolish,or repair any structure,prior to its Issuance.also ELEQ CONTR. LIC.NO. ELEC.
requires the applicant for such permit to file a signed statement that TOTAL ' PERMIT TO
A w m�` he is licensed pursuant to the provisions of the Contractor's License
Fzi Law(Chapter 9(commencing with Section 70000o'Division3ofthe J
i o Business and Professions Code)or that he is exempt theafmm and QTV. PLUMBING PERMIT FEE
¢ ro the basis for lira alleged exemption.Any violation of Section 7031.$ STORIES TYPE CONSTR.
a ;m by any applicant for a pemhil subjects the applicant toa civil penalty
of not more than five hundred dollars($500).)r ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their 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,GOND. 5.00
Code:T'lie Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 5O,FT.FLOOR AREA TOTAL ACREAGE
himself or Through his own employee,provided that such improves
ments are not Intended or offered for sale.If,however,the budding GAS-EA.SYSTEM-1 1 NC.4 OUTLETS 6.00
or improvement is sold within one year of completion, - . - . .00 the owner- GAS EASYSTEM OVER 4 (EA) 2
builder will have tie burden of proving that he did nut buil)or in BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER30IND CON PB Omer
. .00 R
❑ 1,as owner of the property,am exclusively contracting with 0 ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL N0.
and Professions Coda:The Contractor's License Low does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts forsuch projects with it contractors)licensed pursuant to SEWER-SANITARY-STORM EA.2001t/10.00
lite Conlotctor's License Law. TRACT NO. PARCEL NO.
❑ l am exempt under Sec.-.BAKC,for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACG FILE NO,
WORKERSCOMPENSATION DECLARAT[ON . WATER TREATING EQUIP. 5.00
1 hereby uffirnh that 1 have u cenifi,ale of consent to self-insure, ZONING
or a cenificatc of Workers'Compensation Insuronce,or a cerlifietl ENG.SITENO.
copy thercoffSec.3800,Lab.C.I
Policy No. Co cnda y
❑ Cenilied Copy is lore itlj tit' FIRE SPRINK ENERGY T-24
Z Z ❑ Ce rti c py Jed ith the t inspection division.
p Applicant MISC.- REFER TO ORD. Y[:] N� Y ❑ N�
~ m
� Clilt'1']PICATE OP EXEMPTION PROM WORK ERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.C.
lL COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y[:] NE] Y [:] NE)
CL O (This section need not be completed if the permit is for one TOTAL
::) Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued.I shall not employ any person in any manner so as to
O w become subject to lire Workers'Compensation Laws of California.
Umc Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>_ rah! NOTICE TO APPLICANT: If eller making this Certificate of Ex�
YtF Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
y- provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING ACENCY AIR HANDLING UNIT(OVER 10p00GEM.) 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 IS". MICROFILM
3097.Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's NamAddress HEATING UNIT(OVER 100,000 B.T.U.)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
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
I BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
ereby authorize reptesenutives of this city to enter upon the
above-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 CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
granting ofA permiL MECH.CONT. LIC.NO. MECH.
G TOTAL
Dlgnaru�D icanucontroctor '' �S'��- TOTAL
INSPECTOR COPY