09945 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
_ BUI LDI NG PROJECT I DENTI FICATIAD
MIT NUMBER
PER
GILDING 9 APPLICATION PERI,' 09945
ADDRESS /O�4'G ��/O/
V BUILDING - ELECTRICAL-PLUU MBING-MECHANICAL
OWNER' po PLAN CHECK VALIDATION
NAME //ww
.LO 4/ .rt4'lp QTY. ELECTRIC PERMIT FEE
PHONE
cAM1ERAcaoRs OUTLETS-SWITCHES-RECEP 10.00/1.00
,S UC,NJ5;1 0 LIGHTING FIXTURES 10.00/1.00
1,75NITACTORs APPLIANCES-RESIDENTIAL 4.00
ADOR Ess
PHONE 7 ja PANELS 10.00 DATE OF APPLICATION
ORCHITEC PANELS(OVER 200 AMP) 20.00
PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No, SIGNS TRANS. 3.00
ARCH.OF ENG. PEHNAIT VALIDA FIIIIW
ADDRESS SPECIALCIRCUIT 5.00 C y
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH. tl Op
ADDRESS
SERVICE CHANGE 20.00 City Of CiLf'
¢ 2 URenino
�o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
¢
y. I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
waw (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLC. C
r N z Professions Code,and my license is in full force and effect. ❑ ElElz o m - License Class Lic.Number
9 -w Date Contractor
¢ u f BUILDING PERMIT
¢ ¢ w st OWNER-BUILDER DECLARATION
0WU MISC.- REFER TO ORD INFORMATION
j LL H I hereby affirm that 1 am exempt from the Contractor's License VALUATION
HLLOJ Law for the following reeson.(See 7031,5.Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
SE Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
D LL requires the applicant for such permit to file a signed statement that TOTAL ERMIT T
w$ he is licensed pursuant to the provisions of the Contractors License
Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe
a Business and Professions Code)or that he is exempt therfmm and QTY. PLUMBING PERMIT FEE
¢ o the basis for file alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
u ; m by any applicant for a permit subjects the applicant lost civil penalty gLTER-DRAIN& VENT-WATER IEA.) 5.00
of not mom than five hundred dollars(S500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole com pensntiou,will do the work,and the structure is not
intended or offered farsale (Sec 7044, Rumness and Wofessimns DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code: 'rhe Contractor's License Law does nut apply to un owner of
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees,provided that such improve-
mentsarrthrounot tendedoroffered oyees,prove. ided
that
sthe building GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement is sold within one year of completion, - . -OVER 4 IEA.) 2.00 the owner- GAS EASYSTEM
builder will have the burden of proving that he did not build or im- BUILD NG USE
prove lot purpose of Sala.). INDUSTRIAL WASTE INTER. 30.00 RES IND PB ower
❑ 1,as owner of the property,am exclusively contmcting with ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSOR PARCELNO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds of improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant 10
the Contractors License Luw, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKS RS'COMPENSA'I'ION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereoffSec.3800,Lab.C.).
Policy No. Company
0 ❑ Certified copy is hereby furnished FIRE SPRINK ENERGY T 24
Z Z O Certifie�I�p y Is f�J�}v h y inspection Aivisiom MISC.- REFER TO ORD.
O Applicant-�4�'fM�(4�\ L V❑ N V ❑ N[_
CC W CERTIFICATE OF IiXEMPTION FR M WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LL > COMPENSATION INSURANCE PLG.CONTE. LIC.No. PLG.
d 0 (This section need not he em,lard if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
U become subject to lite Workers'Compensation Laws of California.
0 i Dam ApplicantALTER OR ADD TO MECH. 5.00 BUILDING
} Ea N01'ICF TO APPLICANT: If,after making this Certificate of lix-
F'- ? eniption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
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 AGENCY AIR HANDLING UNIT(OVER I0,000CF.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the 309performance
�Civrcunce al the work liar which this permit is issued(Sec. HEATING UNIT TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
1 certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 l
• ordinances n correct 1 agree to comply with all city and county PLUMBING
ordinances end state laws relating m comply
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 BOILER-COMP (Over 100,000 BTU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City ofMISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may i eny way accrue against said City in consequence of the
gran Of thispeen'. MECH.CONT. LIC.NO. MECH. /
-L TDTA / TOTAL
Sigtmmre of Applican rac ur Date
OFFICE COPY