9301 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINE$.- USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
APPLICATION & PERMIT
BUILDING�� 3 V[/�B
o BUILDING -ELECTRICAL-PLUMBING -MECHANICAL --� 1
OWNER'S `(\ \ PLAN CHECK VALIDATION
NAME 1 OTY. ELECTRIC PERMIT FEE
PHONE tt.~-
rvgME TO S OUTLETS-SWITCHES-RECEP 10.00!1.00
�- uC,No, LIGHTING FIXTURES aw 10.00/1.00
noDREss .,,.�,v APPLIANCES-RESIDENTIAL 4.00
PHONE •�" PANELS iQDD DATE OF APPLICATION
OR
HI cr ` PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
-,}
ARCH.OR ENG. PE ATION
ADDRESS SPECIAL CIRCUIT 5.00
ZIP EMP. METERIOR POLE INS. 20.00
AMOTORS SEE FEE SCH. JUL
ADDAoR EBB
�, V 1JVJ
ss
SERVICE CHANGE_-, J,,. 20.00
woo LICENSED CONTRACTORS DECLARATION , TEMP.POLE 30.00 City of Cupertino
1 hereby affirm that I on licensed under provisions of Chaptor 9 .4 ISSUANCE DATE
H z w (commencing with Section 7000)of Division 3 of the Business and
a vAi ly BLDG. ELECT. PLG. MECH.
r h z Professions Cod anJ my license is in full force and effect. -�� ❑ ❑ ❑
O i m o License Class_Lic.Number YLI I Its -_
F m j Date - I (a 8�^ Contractor
a m ,
o: O6U OWNfSR-BUILDER DECLARATION BUILDING PERMIT
INFORMATION
wg u_ , 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u O j Law for the following reason.(Sec.7031.5.Businessand Professions VALUATION $/FT.
_ PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,after.
2 R ¢p improve,demolish,or repair any structurc,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEG,
o¢ requires the applicant far such permit to file a signed statement that TOTAL
A w ore u' •• PERMIT TO
he is licensed pursuant m the provisions of the Contractor's License `rN
rzi Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe +t[+
x ao Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE r
r o the basis for the alleged exemption.Any violation of Section 7031.5 STURIES TYPE CONSTR.
Be �2a � � by any applicant for a permit subjects the applicant foacivil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees wish wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and tile
e 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
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 so.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however.the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that tie did not build or ire- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 E5 IND CON Pe Other
❑ 1,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 1 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.) 1.1
contracts forsuch projeclswith a contractors)licensed pursuant to SEWER-SANITARY-STORM EA:200ft/10.00
lite Contractors License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.AI'.C.for this WATER HEATER W/VENT 6.00
reason
Owner [)ate WATER SYSTEM 5.00 ACC.DATE ACG FILE N0.
WORKERS'COAIPENSATION DECLARATION WATER TREATING EQUIP, 5.00
1 hereby affirm that I have a certificate of consent to sell'insure. ZONING ,ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy N'o. Calnpany
O ❑ Certified ropy is hereby furnished. FIRE SPRINK ENERGY T 24
z Z Cert tied copy Is (led Is fi the city inspection division.
O A}f)fjicalt� MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N❑
y CERTIFICATE OP EXEMPTIO ' (ROM WORKERS' PERMIT ISSUANCE '10.00 FLOODZONE A.L.UX.
W > COMPENSATION I NSURANCE PLG.CONTR. LIC.NO. PLG.
Z (This section need not be completed if the permit is for one TOTAL Y[:] N❑ Y [:] NEIN
hundred dollars(S 100)or less.)
U O I certify that in the performance of the work for.),fell this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mil is issued,I shall not employ any person in any manner so as to
OL) become subject to the Worker:Compensation Laws of Calilorniu.
Ditc Applicant BUILDING
>_ d m NOTICES 'f0 APPLICANT: If,after oinking this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
F 2 emption,you should become subject to the Worker:Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this perm
permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10000.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,CI,C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and stale that tie above VENTILATION FAN (SINGLE)' 4.00
• information is correct. 1 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
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
I (We) agree to save, indemnify and keep mouless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses w),icll PERMIT ISSUANCE 10.00
CONST.TAX
may in any way uccme against said City in consequence of the L _
nitngof this perm.L MECH.CONT. LIC.NO. MECH.
- TOTAL TOTAL
gnatumof Appl nCCont a for nlc
INSPECTOR COPY
1