09592 APPLICANT TO FILL IN INFOFAMWTION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTI FICATI N
PERMIT NUMBER
BUILDING G I I APPLICATION & PEFW09592
FDDRE55
egg BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
® ONE
TRACT
NOR'S
SNAME I- 13 UTLETS-SWITCHES-RECEP 10.00/1.00 1 y� =
1rORs lc,No, 3 LIGHTING FIXTURES 10.00/1.00 OS
ADDRESS410$ PPLIANCES-RESIDENTIAL 4.00
3393 ELJaeln2 PRONE/ C PANELS 10.00 GATE Of APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 0/ PLAN CHECK FEE P.C.N0.
O
ENGINEER
Lie NO. SIGNS TRANS. 3.00
ARC OR
Ervc' SPECIAL CIRCUIT 5,00 65 PERMIT VALIDATION
TIP TEMP.METER OR POLE INS. 20.00 'p W
APPLIDDIR rS
AOORMOTORS SHP SEE FEE SCH. 36
E55 /
3 E 1.4 L%/r> SERVICE CHANGE 20.00 ��n A(/�
o ¢ z TEMP.POLE 30.00
r
00 LICENSED CONTRACTORS DIiCLARA'FION
aca
� I hereby affirm that I am licensed under provisions of Chapter 9 - ISSUANC DATE
„ a o (commencing with Section 7000)of Division 3 of the Business and BLDG. EL T. PLG. MECH.
H w z Professions Cod rv1 my license is in full fm e'n [tqfr Ly W►'.�'�' 'a
z o m- Lianse�la.�s /� Lie.Nwnber SRa� El
o m r Date Conlructor nC klSl
a u f
¢ G PERMIT
¢ w OWNER-BUILDER DECLARATION _JIN BUIL INORMATION
w ; LL H I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
H w o j Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALU ION $/FT.
Code:Any city c r county which requires a permit to coustmel,aheq
2 ¢ ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC-NO. ELEC.
St u requires the applicant for such permit to file a signed statement that - TOTA PERMIT TO
A w w he is licensed pursuant to fire provisions of the Contractor's License
se Law(Chapter 9(commencing with Section 7000)ofluvision 3 of the
4 a Business and Professions Code)or that he is exempt therefrom mid F Z
¢ H m the basis for the alleged exemption.Any violation of QTY. PLUMBING PERMIT FEE
$eCtion 7031.5 STORIES TYPE CONSTR.
e- by any applicant for a permit subjects Ole applicant to a civil Penally ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars 0500).):
• ❑ 1,as owner of the property,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
tended 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 improve-
ntsare not intended aroffered for sole.If,however,the budding GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of complelioo, - . - . .0
the owner- GAS EASYSTEM OVER 4(EA) 20
builder will have the burden of proving that he did not build or int- BUILT USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND PB Other
Cl 1,as owner of the property,um exclusively contracting with ❑ El El ❑
licensed contradurs to construct the project ISec. 7044, Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSOR PARCEL NO.
and Professions Code:The C'ontractor'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 will)a conlmctmrts)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ tum exempt under Sec,.,R&P,C.for this reason WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSA'no%DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that 1 have a certificate of consent to sel&insure.
r a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy theregfifSee.3800,Lab.CJ.
Policy No. O Company Asa
O ❑ Certified copy is hereby furnished, FIRE SPRINK ENERGY T 24
Z Z N Certiljyd��opy�y 1-t41 q th Ip� �ty inspection division.
O Applicant_ (d�lC+st_p.L��i„l( MISC.- REFER TO ORD. YE] NE] Y � N�
~ r/+ PERMIT ISSUANCE 10.00
- CER'1'IPICATIi OP F.XIi\IPTION PROA1 WORKERS' FLOOD ZONE A.L.UL.
W > COA/PIiNSWION INSURANCE PLG.CONTR, LIC.NO. PEG.
EL0 1'fhis section eed not he completed if the permit is for one TOTAL Y❑ N0 Y N�
U O hundred dollars IS 100)or less.)
I certify that in Ore performance o1the work In,.[rich'It"per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mil is issued,I shall not employ any person in any manner so as to
U become subject to the Workers Compensation Laws of California.
ED Date Applicant BUILDING
>_ m NOTICE TO APPLICANT': If,after nuking this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
Z 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 10=CF.M.) 4.00
CONSTRUCTION Ll'NDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that [here is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued ISec. MICROFILM
3077.Civ.C.f HEATINGUNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's nddre.. HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that l have read thislicmiort and state that the above VENTILATION FAN (SINGLE) 4.00
information n correct 1 agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and State laws aches m building construction, and
hereby enthoed representatives lot ins of this city es 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 PERMIT ISSUANCE 10.00 CONST.TAX
may in a ay accrue against said City in consequence of the
gm0 f is permi. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signature of Ap mant/Contractor Date
OFFICE COPY