9330 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENT[FICATI ON PERMIT NUMBER
a=' ' BUILDING APPLICATION & PERMIT
ADDRESS D 9330
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
O.NERfF PLAN CHECK VALIDATION
NAME CITY. ELECTRIC PERMIT FEE
yuZ2NAME Ac oRs OUTLETS-SWITCHES-RECEP 10.00/1.00
4,4A
Ic.rv0. LIGHTING FIXTURES 10.00/1.00
co Ac
ADDRESS APPLIANCES RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.No. SIGNS TRANS. 3.00
AARCH,OR DDRESS ENG SPECIALCIRCUIT 5.00 PERytyL�rydgnTlON
ZIP EMP.METER OR POLE INS. 20.00 AUGT/q�,�LVJ,
ADDRESS MOTORS SEE FEE SCH. A2 3 1985
ADDRESS
r SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 City of Cupertino
G o U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and BL ELECT: PLG. MECH.
FD,z Professions Code,and my license is in full force and effect. ❑ ❑ ❑ 1
z o m - License Class Lic.Number
0 0 w Date Contractor
¢ D s BUILDING PERMIT .
;¢ on OWNER-BUILDER DECLARATION INFORMATION
wo a H 1 hereby affirm that 1 am exempt from the Contractor's License MISC-- ",REFER TO ORD
3 u y P VALUATION $/FT.
F .. o ¢ Law for the following reason,(Sec.703L Business to construct,
Professions PERMIT ISSUANCE 10.00
Code:Any mo sh countypair any structure p prior toconsuanc .alsolter, /
,Q Q 0 improve,demolish,or repair any slmclure,prior N i[s issuance,also ELEC.CONTR. LIC"NQ ELEC.
w
- O¢ requires the applicant for such permit to file a signed statement that j TOTAL "PERMIT TO
a w m" he is licensed pursuant to the provisions of the Contractor's License
z i Lew(Chapter9(commencing with Section 7000)of Divisiou3ofthe '
¢ Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE '
¢ r o the basis for[he alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR:
u ; m by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars($500).): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ I,as owner of the property,or nhy employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCG GROUP RES.UNITS
their sole compensation,will do the work,and the sf mcture is not
intended or offered for sale(Sec. 7044, Business and Profusions - DRAINS-FLOOR,ROOF,AREA,COND- 5.00
Code:The Contractor's License Law does not apply to an owner of -
propertywhobuildsorimprovesthereon,and who docs such work FIXTURES-PERTRAP 5.00 SO.FT.FCOORAREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
I4. meats a re notintended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one your of completion,the owner GAS EASYSTEM OVER 4(EA) 200
builder will have the bu Nen of proving that he did not build or ire - . - . .
- BUILDING USE
prove for purpose of sale.). _ INDUSTRIAL WASTE INTER. 30.00 E IND CON PB Daher
❑ 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 ASSESSORS PARCEL NO.
andProfessions Codec 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.) 1.00
contracts for such projects with u contractors)licensed pursuant vh
the Contract s feet...Law. SEWER-SANITARY-STORMEA.200ft/10.00 TRACT NO. PARCEL NO.
1Ca4
❑0n Iva xcruunder Se BAP.C.for this WATER HEATER W/VENT 6.00
..
Owne' r WATER SYSTEM 5.00 ACC.DATE 'ACC.FILE NO.
' WORK F;RS'C PENSA'TION DECLARATION WATER TREATING EQUIP. 5.00
hereby affirm that 1 have a certificate of consent foSelf-unsure. ZONING
On a certificate of Workers'Compensation Insurance,or a certified ENG:SITE NO.
copy t heart f(Sec.3800,Lab.C.).
Policy No. Company r"
(] ❑ Certified copy is hereby furnisheJ. FIRE SPRINK ENERGY T-24
p ,. Applicant❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD. v N Y ^* N
I,. ❑ ❑ ❑ "
I, ~ wPERMIT ISSUANCE 10.00 FLOODZONE A.L.uc.
CERTIFICATE OF I XIiMPTION FROM WORKERS'
W > COMPENSATION INSURANCE PLG.CONTR. ❑C.NO. PLG.
IL O (This section need not be completed if the permit is for on. TOTAL Y❑ N❑ Y❑ 'N❑
0 Z hundred dollars IS 100)'tr less.)
U O 1 certify that in the performance of the"work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any person in any reamer so as to
0 becomesubject to theWorkers'Compensation Laws of California. /a
a Datc Applicant ALTER OR ADD TO MECH. 5.00 BUILDING fl/
NOTICE TO APPLICANT: IL after making[his Cer(il'icate of Ex- .
FZ emplion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLANCHECK
provisions of tee Labor Code, you must forthwith comply with FEE '
CJ such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 - SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the 309performance
C,,C ance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Leader Name HEATI NG UN IT(OVER 100,000 B.T.U.)9.50
Lend`er's Address ELECTRIC
11 certify thin lhovc read this application and state tint the above VENTILATION FAN (SINGLE) 4.00 - -
•� information is correct.I agree to comply with all city and county BOILER-COMP(3 H.P.of 100,000 B.T.U.1 6.00 PLUMBING
ordinances and state Taws relating to building construction, and
hereby authorize representatives of this city to anter upon the
above-mentioned property for inspection purpoBOILER-COMP (Over 100,000 BTU(SEE FEE$DH. MECHANICAL
se.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, co.aw..dexpenses which PERMIT ISSUANCE 10.00 CONST.TAX
may m y way accvme against said City in consequence of the
grand o this penniL MECH.CONT. LIG NO. TOTAL TOTAL
Si nes /D to
INSPECTOR COPY