9457 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT 1 DENTI FICATI ON PERMIT NUMBER
BUILDING
OO APPLICATION & PERMIT 457
AD Ess y �"
).DING - ELECTRICAL-PLUMBING-MECHANICAL 9
OWN`IRS PLAN CHECK VALIDATION
NAME CITY. ELECTRIC PERMIT FEE
PHO / a
• NAMEA °P5 UTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S PPLIANCES-RESIDENTIAL 4.00
ADDRESS
G - PANELS 10.00 DATE OF APPLICATION
ARLRITECi
OR PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO,
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRESS E.G. SPECIAL CIRCUIT 5,00
Zm TEMP.METER OR POLE INS. 20.00
APPLICANT'S
ADDRESS MOTORS SEE FEE SCH. AUG 2 d ieq�x
/!7®J
SERVICE CHANGE 20.00
C o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 .City of Cupertino
a U I hereby affirm that I in licensed order provisions of Chapter 9 ISSUANCE DATE
, (commencing with Section 7000)of Division 3 of the Business and
G. ¢ y BL ELECT. PLG. MECH.
F w z Professrns CO a r i'ense is in full force nd e 1'e ❑ ❑
z o w License Class hies Nundrnr
O m = Uale ConlmdOr
ric m ¢ a OWNER-BUILDER DECLARATION / BUILDING PERMIT
0 u U INFORMATION
Rw 3 y I hereby uffinn that I um exempt Irom the Contractor's License MISC.- REFER TO ORD
R a- rL o¢ Law for the followingreason.(Sec.7031.5,Business and Professions pERM1T ISSUANCE 10.00 VALUATION $/FT.
Code:Any city or e0unly which raquiresx permit toconstruer.1te,
ce ¢ Q p improve,de rolisli,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.I'
CLL req aired the applicant for such permit to lilt a Pignet statement that TOTAL
a w y he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
Ri > Law(Chapmr9(comnmeneingwidh Secli0n7000)of Division3ofthe
i o Business and Professions Code)or that he is uxempt Iherefmm and QTY. PLUMBING PERMIT FEE
the basis for the alleged exanption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
aim by any applicant for a permit subjects Ole applicant to acivil penalty ALTER-DRAIN -WATER (EA.) $,00
of not more than five hundred dollars(55001.):
❑ 1,as owner of the prnpeny,or my employees With wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sine (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5,00 SO.FT FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
Cuts are not intended or offered lot sale.Ili however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,bthe owner- GAS-EA.SYSTEM OVER 4 (EA) 2.00
builder will have the burden of proving that he did not u - .
ild or im- BUILDING USE
prove for purpose Of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND O PB Omer
0 1,us owner of the property,am exclusively contracting with1-1 El
licensed contractors to construct the project(Sec.7144,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSO PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts forl.eld projeclswith a contractors)licensed pursuant to SEWER-SANITAR V-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ l am exempt under Sec.-.BAP.C,for this WATER HEATER W/VENT 6.00
on
Owner Date WATER SYSTEM 5.00
ACC.DATE ACG FILE NO,
WORK ERS'COMPENSAI'ION DECLARATION WATER TREATING EQUIP. 5.00
I here y uffinn that I have a certificate of consent la sell'-insure. ZONING
or a cer f Cale o Workers'Compensation Insurance,or a certi fief ENG.SITE NO.
copy th o Sc A 0.Lab.C.).
Po[icy0npuny
0 Cc,th ed c s hereby f )ished
z Z 0 Cerlifw y filed/�It r} c ri�tion division. FIRE$PRdNK ENERGY T 2
C) Applicant � � MISC.- REFER TO ORD. Y NE] Y ❑ N[
CC �+ v- PERMIT ISSUANCE 10.00
ELI - CERTI GOPd l' SA flOTIFROM WORKERS' FLOOD ZONE A.L.u.L.
IL COd not e couN INSURANCE itthe PLG.CONTR. u0.N0. PLG. O ❑ '❑ ❑
CL O afire delta,n need not be completed if the permit is for ono TOTAL V N V N
J Z hundred dollars f4100)Or loss.)
U O 1 certify that in the iratur lance of the work for which this our. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F Init is issued, I shall nod employ airy person in any mons,s0 as to
U W become subject to the Workers'Compensation Laws of California
ED Date-Applicant BUILDING
>_ to NOTICE '10 APPLICANT': If,after making this Certificate of lis- ALTER OR ADD TO MECH. 5.00
F Z endption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you .dust forthwith comply witA
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M,) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 1000DGFM.) 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 wink for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name H EATI NG UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
1 certify that l have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and slate laws relining to building construction, and BOILER-ODMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(we)'-wee to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which
PERMIT ISSUANCE 10.00 CONST.TAX
may in an ay accrue adnst ,d ity i, consequen of he -
granl g its mit, MECH.CONT. LIC.NO. MECH.
TOTAL ' TOTAL
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INSPECTOR COPY
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