9268 (2) APPLICANT TO FILL IN INFORMATION W HIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
Bt,LD,NG APPLICATION & PERMIT
D H S
IPIG - ELECTRICAL-PLUMBING-MECHANICAL9268
NAME PLAN CHECK VALIDATION
. OTV. ELECTRIC PERMIT FEE
PRONE
c R TORS OUTLETS-SWITCHES-RECEP 10.00/1.00
A 1
LIC.NO �9 LIGHTING FIXTURES 10.00/1.00 /x /J/ �
AO Ess
CON Across PPLIANCES-RESIDENTIAL 4.00 / 1/iC/
p
// ) PRONE - 7 PANELS 10,00 DATE OF APPUCATIONI'�
EiA
cerrscr PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P. .NO.
"R r
NGINEER
LIC.No. SIGNS TRANS. 3.00 '
ADDRESS ENG, SPECIAL CIRCUIT 5,00 PERMIT V}ryl�j4N
ZIP EMP.METER OR POLE INS. 20.00 QQ��/i'j�
APPLICANT'S MOTORS SEE FEE SCR. JUL
ADDRESS 1_85
rpp-.1pqqppp
2
SERVICE CHANGE 20.00 V
o OLICIiNSGU CONTRACTORS DECLARATION TEMP.POLE 30.00 .City of Cupertino
rt v v 1 hereby affirm that 1 am licensed under provisions of Chaplet 9 ISSUANCE DATEIII
m, e_ (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. CH.
r G z Professions Code,and my license is in full force and effect. ❑ ❑ ❑
z o - License Class Lie.Number
O Hve Date Conlmctor
1-W
- s BUILDINg E MIT
p m w u OWNER-BUILDER D17CLARATION INFORMATION
is OA MISC- REFER TO ORD
w ea LL H I hereby affirm that I am exempt from Luce Contractor's License VALUATION $/FT.
H I� 0< Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
ac WQ 4o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
- O , Inutile,the applicant fix such permit to file u signed statement till,( TOTAL PERMIT TO
A w m u he is licensed pursuant to are provisions of the Contractor's License _
r z a Law(Chapter 9(commencing with Section 7000)of Division 3 oflhe
E i o Business and Plm'"sions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE IJ
H o the basis for the alleged exemption.Any violation of Section 7031.5 STrIE9 ilif TYPE CONSTR.
a ;m by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than Live hundred dolllus($500)J:
O 1,as owner of the property,or my employees with wages as BACK FLOW 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,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 docs such work FIXTURES-PER TRAP - 5,00 SO.FT FLOOR AREA TOTAL ACREAGE
S himself'or through his own employees,provided that such improve.
Sw
ts are not intend,,]or offered for sal,If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
L
orionmovereent is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
"Do,for purposeofsale.). INDUSTRIAL WASTE INTER. 31EE71 IND CON PB Other
O 1,as owner of the property,am exclusively contracting with X 1 ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions CG,]e:'fhe Contractor's License Law does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
...tracts for such projects with a contmctmi licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
0 lam exempt under Sec.-,BAP.C.for this WATERHEATER W/VENT 6.00
reason L
OwnerDate WATER SYSTEM 5.00 ACC.DATE Ace.FILE No.
WORKP:RS'COMPENSATION DECLARATION WATER TREATING EQU IP.
I hereby affirm that I have a certificate of-consent to selfhast re. ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE N0.
copy theceof(Scc.3800,L.DC.).
Policy No.-C, ;yApy` -
O O Ccs ili,d t1 is h• iSy fl tshcd. RE SPRINK ENERGY T34
Fp A amtifie cop fit haltil, ci y inspection division. MISC.- REFER TO ORD. Y ❑ N Y ❑ N❑
N PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C,
LU CIiR GYI'l. P EXEMIN'INS FROM WORKERS'
W COM lot be comIONpleted
INSURANCE. PLG.CONTE. LIC:NO. PLO. Y❑ N❑ Y ❑ N❑
d O (Thin dollars Sued not be completed if the permit is for nuc TOTAL
� Z hundreJ dollars IS 100)or less.)
U O 1 certify that in the Performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
U_ F mit is issued,I shall not employ any person in any manner so as to
0 become subject to the Workers'Compensation Laws of California. BUILDING
n Dat, Applicant ALTER OR ADD TO MECH. 5.00
} to . NOTICE TO APPLICAN 1': IL after making this Certificate of F..
F Z_ enrption,you should become subject to the WorkersCompensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply wits FEE
U such provisions or this permit shall he deemed revoked AIR HANDLING UNIT(TO 10MCF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.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(Sac. MICROFILM
3097,Cre.CJ, HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's IN...
Lender's Address HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
~. ordinances n axmeL I agree to comply with all city and county PLUMBING
ordinances and state laws relating c M building construction,nd co andmy BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorise representatives of this city to enter upon the BOILER-COMP(Over 100,000 STU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. t
Cupertino against liabilities,judgments. costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may Ii any way aces a against said City in consequent• of the
gra tg of pen", MECH.CONT. LIC.NO. MECH.
` w TOTAL TOTAL
Signator f want ontraaor _e '
INSPECTOR COPY