09526 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT p9526
ADDRESS
2(fk OF } BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWN ,�/� PLAN CHECK VALIDATION
NZE �7 (, OTY. ELECTRIC PERMIT FEE
n PRONES/1- Oki
NAME s OUTLETS-SWITCHES-RECEP 10.00/1.00
If IC.NO, LIGHTING FIXTURES 10.00/1.00
ADDRESS TRAc7Ons APPLIANCES-RESIDENTIAL 4.00
PHONEd9 -
PANELS 10.00 DATE OF APPLICATION
A E " PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00 1
AARC
DDRESS ENG. SPECIALCIRCUIT 5.00 RAW
LIGATION
ZIP TEMP.METER OR POLE INS. 20.00 AUGAPPLI MOTORS SEE FEE SCH. G 2 3 1J05
ADDRESS
IJO J
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION ITEMP.,POLE 30.00 City of Cupertino
uu I herehy affvm that I am licensed under provisimns of Chapler 9 ISSUANCE DATU.
a, G oNi (cunvn
necing with Section 7000)of Dlvisiun 3 of the Business and BLDG. ELECT. P _ MECH.
H m z Professions Code and my license is in full force nd effect ❑ ❑ ❑
z o T - Liccnse C nss Lie.Number .O
O z H o Da1c �. �� Contractor
¢ ys - BUILDING PERMIT
¢ ur w ¢ OWNER-BUILDER DECLARATION INFORMATION
oAU MISC.- REFER TO ORD -
w3 y 1 hereby affirm that I am exempt from the Contractor's License
LL o'a Law for the following reason.(See.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATIONS/FT.
Code:Any city orcounty which requires a permit to construct.alter,
or u, Q 2 Improve,demolish,or repair any structure.prior to Its Issuance,alio ELEG CONTR. LIC.NO. ELEC.
- O LL 'requires Ore applicant for such permit to file a signed statement that TOTAL P R IT TO
A w m m he is licensed pursuant to the provisions of the Contractor's License
H z r
Law(Chapter 9 commencing with Section 7000)of Division 3 ofthe
¢ Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
K'F o Ore basis for the alleged exemption.Any violation of Section 7031.5 STO I
ES TYPE CONSTR.
pgr' by any applicant fora permit subjects IIIc applicant toa civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars(55001.):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do lire work,and the structure is not OCC.GROUP RES.UNITS
imcndcd or offered for sale (Sea 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-PERT RAP 5.00 'O(7 SO,FT.FLOOR AREA TOTAL ACREAGE
meats are oti menhrough ds ownemployees,for
Spm If,ed however.the
improve- GAS-EA.SYSTEM-1 6.00 0U
menus are not intended or offered for sale.If,however-the building n
or lderrwill have
t is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE ,
builds will have the burden of proving that he did not build or ire- E IND CON PB Omer
Prove 1,aso nee of sale.). INDUSTRIAL WASTE INTER. 30.00 O ❑ ❑ ❑
❑ d as owner of the property,he exclusively contracting with
licensed contractors to construct the project 1&c. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 sl ASSESSORS PARCEL NO.
and n owner of Code:The Contractor's License Law docs not apply
to frowner of such
yswho witbuildsor trimprovesensed p,
and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/10.00 /QV TgACr NO. PARCEL NO.
❑ lam exempt under Sec. .B.&P.C.for this WATER HEATER W/VENT 6.00 b U
reas lin
Owner Date WATER SYSTEM 5.00 (K) ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure ZONING or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No. - Company
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
z Z [J�Certil led c py is filed ith the city inspection division.
O Ap ant >Ph C, E, MISC.- REFER TO ORD, v� N� v ❑ N❑
CC y CF,RTIF C TF.OEXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 UG FLOOD ZONE A.L.u.C.
L COMPENSATION INSURANCE PLG.CONTR. ❑C.NO. PLG. /Yt
IThis' section need not be coRgd,tcd if the permit is for one TOTAL W Y N Y N[]
hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- OTV. MECHANICAL PERMIT FEE FEE SUMMARY
IL 1- mit is issued,I shall not employ any person in:my manner so as to
Ow become subject to the Workers'Compensation Laws of Californi^. BUILDING
n Date Applicant ALTER OR ADD TO MECH. 5.00
} to NO'T'ICE TO APPLICANT: If,after making Oris 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 FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO IO=C.F.M,) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the 3097 sCiv C .)�ee of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lenders Address ELECTRIC
Icertify that l haveread this application and It that theahovc VENTILATION FAN (SINGLE) 4.00
intonnntion is correct.I agree to comply with all city and county PLUMBING Od
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or100,000&T.U.) 6.00
hereby authorize representmives of this city U enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE BCM. MECHANICAL
aboveanentioned property for inspection purposex.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs andexpenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any vv((ay accrue against said City in consequence of the
grand fthd'permit. MECH,CONT. LIC.NO. MECH.
�r i t 6l S(l �yr TOTAL TOTAL
Sig antt/�C n�rac[o �a '�T
INSPECTOR COPY