C9128 APPLICANT TO FILL IN,INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENT[F I CATION it PERMIT NUMBER
BUILDING APPLICATION & PERMIT 1, g 128
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MA
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� ,i BUILDING-ELECTRICAL-PLUMBING-MECHANICAL /
ER'$® PLAN CHECK VALIDATION NAME G.... DTV. ELECTRIC PERMIT FEE
ONE 3 O
LDNTRFCT Y
NAME UTLETS-SW'TC
HES-RECEP 10.00/1.00
LIC.No, LIGHTING FIXTURES 10.00/1.00 A
c C DRESS rows
AODREss APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMPI 20,00 PLAN CHECK FEE P.C.NO.
OR
O
ENGINEER
' LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG, PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH. /�
ADDRESS
t SERVICE CHANGE 20.00
(;L
wo o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 (,//TJ�S
a U o I hereby alt'ino that I ani licensed tinder provisions of Chapter 9 ISSUANCE DATE
w [commencing with Section 7000)of Division 3 ofthe Rosiness and BLDG. ELECT. PLG. MECH.
yi Professions Code,and my license is in full force and effect F-1 ❑ El z o w - License Class Lie.Number
o z F D Date Contractor
a y s BUILDING PERMIT
IS S, w u,- OWNER-BUILDER DECLARATION INFORMATION(
eeC rs. MISC.- REFER TO ORD
u 1 hereby ali'irm that 1 am exempt from the Contractor's License VALUATION $/FT.
F ec o< Law for the Billowing reason.(Sec.7031.5.Bnsinuss and Professions PERMIT ISSUANCE 10.00
Code:Any city orcounty which it,uires a permit t o const rue L alter, C(
rtQ p improve,ch mDlish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
- D M requires(lie applicant for such permit t0 file a signed statement that TOTAL PERMIT TQ
n w m he is licensed pursuant to the provisions of the Contractor's License f/`tY•,
F z es Law(Chapter 9(commencing with Section 7000)of Division3 ofthe Z p
< Business and Professions Camel or that he is exempt therefrom and DTV. PLUMBING PERMIT y FEE T B"�
at = $ the basis for the alleged exemption.Any violation of Section 7031.5 1 1 ( STORIES TYPE CONSTR.
by any applicant In,a perinit subjects the applicunito a civil penalty &VENT
-WATER IEA.) 5.00
of not more than five hundred dollars IS500).l: ALTER-DRAINIf
❑ 1,as owner of the property,or my employeeswi th'wages as BACK F LOW PROTECT.DEV ICE 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,GOND. 5.00
Code:'rite 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-
mentsarcnot intended or offered for sale If,however.the building GAS-EA,SYSTEM-1 1 NC.4 OUTLETS 6.00
or inhprovement is,sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will Inne the burden ofproving that he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ I,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..
and Professions Code:The Contractor's License Law chi 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 to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO, PARCEL No.
❑ Ism exempt under Scc. .li.&N.C.for Wis WATER HEATER W/VENT 6.00
Tetsuo
Owner;+ <<- Date a ro WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
W'ORKERS'COMYENSAI'ION UECL AT 1oN o WATER TREATING EQUIP. 5.00
I hereby affirm that I have a Certificate of consent toself-insure, ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
v, copy tIu,cof(Scc 3800,LaDCA
s Policy No. Company
O ❑ Ca tilicJ mpy'is he by lurnishcd. FIRE SPRINK ENERGY T 24
z Z ❑ Certified copy is fled with the city inspection division. MISC.- REFER TO ORD.
0 Applicant Y ❑ N❑ Y ❑ N❑
ir In CER1'IFICLTE OF IiXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOOZONE AL.RC.
W > COMPENSATION INSURANCE PLG.CONTR. }LIC.NO. PLG.
Z [this scutula need nut be complcmd if the permit is for ono TOTAL V C:] N❑ Y ❑ N❑
Z hundred dollars IS 100)or lessA
U O 1 certify that in the performance of the work for which this per- OTV. y\ MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
O become subject to the Workers'Compensation Lawsof California.
u Date ApplicantALTER OR ADD TO MECH. 00 BUILDING
5.
aC) SZ1
} ED NO'TIC17 '1'0 APPLICANT: If,after making this Certificate of Ex-
crap ion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must I..thwith comply with FEE
U such provisums or this permit shall be deemeel revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4,00
CONSTRUCTION LENDING AGENCY AIRHANOLING 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 performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). ` HEATING UNIT(70100,000 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 l have read Obis application and Stam that the above, VENTILATION FAN (SINGLE) 4.00
• information is correct. I agrae to comply with all city and county' PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMM 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 FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.ISSUANCE 10.00 CONST,TAX
may in any way accrue against said City in consequence of the
granting of this permit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL C,?Signature of Applicant/Contractor trate I
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INSPECTOR COPY