09946 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BA L POINT PEN ONLY
BUILDING PROJECT I DENTI FICA APPLICATION & PER PERMIT NUMBER
toNG f
DDRESS
� ,a/!s 09946
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWrvER'S PLAN CHECK VALIDATION
NAME 44
f "O •el AigK DTY. ELECTRIC PERMIT FEE
vHONE
rcaAmeRnCTOR roRs UTLETS-SWITCHES-RECEP 10.00/1.00
<AUuc.NO. LIGHTING FIXTURES 10.00/1.00
f,U Acrons PPLIANCES-RESIDENTIAL 4.00
A
ORE SS
PHONE PANELS 10.00 DATE OF APPLICATION
ORRLRITEC PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO, ISIGNS TRANS. 3.00
AARCH,OR
DDRESS ENG. SPECIAL CIRCUIT 5.00 PEgpglr�e�DATIDN
zap EMP.METER OR POLE INS. 20.00 6"'fqq�11J
APPLICANTS MOTORS SEE FEE SCH. OCT b 185
ADDRESS
SERVICE CHANGE 20.00
w o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 City of Cupertino
a U U I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
wQ H (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. M C .
r D z Professions Code,and my license is in full force and effect ❑ El 11 License Class Lic.Number
o z r ow Date Contractor f
m re BUILDING PERMIT
a w < OWNER-BUILDER DECLARATION INFORMATION
iL o A MISC.- REFER TO ORD
X g u N I hereby affirm that I am exempt from the Contractor's License VALUATION S/FT.
F LL o a Law for the following reason.(Sec.7031.5•Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires permit to construct•alter.
rt2¢ improve,demolish•or repair any structure.prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
ROLL requires the applicant for such permit to file a signed statement that TOTAL I P RMIT TO
N m he is licensed pursuant to the provisions of the Contractor's License
H 2 T Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
r O the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
d '; $ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 DCC.GROUP RES.UNITS
their sole compensation,will do the work,and lite 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 does such work FIXTURES-PER TRAP 5.00 so.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such intprove-
,,,cats are not intended or offered for solo.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). . INDUSTRIAL WASTE INTER. 30.00 RES IND PB Om.,
❑ I,as owner of the property,am exclusively contracting with ❑ El [V
❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORPARCEL No.
and Professions Code: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 a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200f1/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-,B,&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACO.FILE NO.
W'ORKFRS'COMPENSA'TION DECLARATION WATER TREATING EOUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(See3800,Lab.C.).
Policy No. Company
C) ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
❑ Certifies ry is 1'I wi t cit inspection division. C
-MISREFER TO ORD.
Z 0 Applicant Y ❑ N Y ❑ N❑
OC w CERTIFICATE OF EXEMP'T'ION 4M WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.c.
LU > COMPENSATION INSURANCE: PLG.CONTR. ❑C.NO. PLG.
CL a Z (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ElNE]N
hundred dollars($100)or less.)
) 0 1 certify that in the performance of tire work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LLP mit is issued,I dull not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of Calilirniu.
ED Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} ED NONCE TO APPLICANT: If,uhei-making this 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 10MC.F.M.) 4.00
CONSTRUCTION L17NDING 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(Sec. MICROFILM
3097,Cie C.), HEATING UNIT(TO 100,000 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 1 have read this application and state that the above Ja VENTILATION FAN (SINGLE) 4.00
. information is correct. I agree to comply with all city and countyLUMBING
ordinances and state laws relating n building construction. and BOILER-COMP(3H.P.or100,000B.T.U.) 6.00
hereby authorirc 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 ex panus which CONST.TAX
may in any way accrue against said City in conscyuence of the PERMIT ISSUANCE 10.00
granting of this permit MECH.CONT. LIC.NO. MECH.
0--Z TO TOTAL
SIVriatr7fie-ofpp scan ntr ctor Date
OFFICE COPT