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C9367APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION APPLICATION &PERMIT BUILDING - ELECTRICAL -PLUMBING -MECHANICAL PERMIT NUMBER �� D ADRESSILDIN NEE' NAME OTY. ELECTRIC PERMIT FEE PLA HECK VALIDATION PH NAMEA S OUTLETS-SWITCHES-RECEP 10.00/1.00 LIC, LIGHTING FIXTURES 10.00/1.00 C" ADDRESS APPLIANCES- RESIDENTIAL 4.00 PANELS 10.00 i%6 1�aPI DATE OF APPLICATION OR ENGINEER EN LIC. No. PANELS(OVER 200 AMP) 20.00 PLAN CHECK FEE P. C. NO. SIGNS TRANS. 3.00 ARCH. OR END ADDREsS ZIP SPECIAL CIRCUIT 5.00 PE�,pQ VALIDATION i�,Q, AUG. - EMP. METER OR POLE INS. 20.00 ADDRESS MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 .Cifj of Cupertino LICENSISD CONTRACTORS IN CLARATION TEMP. POLE 30.00 I hereby affirm that 1 am licensed under provisions of Chapter (commencing with Seclion 7000) of Division 3 of the Business and Professions Code, and my license Is III full force and effect License Cl.,, -'V Lie.Numb ISSUANCE DATE BLD ELECT PLG. MECH Date _ Contraclo BUI D G PERMIT INFORMATION OWNER -BUILDER DECLARATION I hereby affunl that 1 um exernpf Gum tire on e Ctmetoiicen s LseVALUATION Law lot the following reason. (See. 7031.5. Husinessand Professions Code: Anycity orcounty which requires a permit to construct, alter, MISC. - REFER TO ORD PERMIT ISSUANCE 10.00 n SIFT, ELEC. CONTE. LIC, NO, ELEC. TOTALP improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to filo a signed statement that he is licensed pursuant to the provisions of the Contractor's License L EMIT TO OTY. PLUMBING PERMIT FEE Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and 7 / the basis for the alleged exemption. Any violation ol'Section 7031.5 by any applicant for a permit subjects the applicant toacivil penalty not more than five hundred dollars ($500f r: T IES Q� P CONSTR. �0of � ALTER -DRAIN (EA.15.00 ❑ I, as owner of the property, or my enployees with wages as their sole compensation, will do the work, and the structure is no[ BACK FLOW PROTECT. DEVICE 4.00 OCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AR EA, COND. 5.00 intended or offered for sale (Sec. 7044, Business and Professions Code: Ilse Contractor's License Law does not apply to an owner of FIXTURES - PER TRAP 5.00 GAS - EA. SYSTEM - 1 1 NC. 4 OUTLETS 6.00 property who builds or improves thereon, and who docs such work himself or through his own employees, provided that such improve- ments are not intended or offered for sale. If, however, the building SO. IT. FLOOR AREA TOTAL ACREAGE or improvement is sold within one year of completion, the owner- builder will have the burden of proving that he did not build or im- GAS- EA. SYSTEM -OVER 4 (EA.1 2.00 BUILDINCIiUSE prove for purpose ofsale.)' ❑ I, as owner of the property, am exclusively contracting with RES IND PB Omer INDUSTRIAL WASTE INTER. 30.00 licensed contractors to construct the project (Sec. 7044, BusinessLAWN and Professions Code: The Coatructor s License Law does not apply to an owner of property who builds or improves thereon, and who . SPRINKLERS - 1 INC'S V.B. 600 ASSE550 RCEL N0. LAWN SPRINKLERS - OVER 5 (EA.) 1.00 contracts for such projects with a contractortsl licensed pursuant to the Contractor's License Law. ❑ Iamexemptunder Sea ,B.&I'.C.tirrthis reason SEWER -SANITARY -STORM EA. 200ft/10.00 TRACT NO. PARCEL NO. WATER HEATER W/VENT 6.00 Owner Date WATER SYSTEM 5.00 A.CC.OATE ACG FILE NO. WATER TREATING EQUIP. 5.00 WORKERS'COMPENSA'1'ION DECLARA'nON 1 hereby affirm that 1 have a cioluieme of consent to self -insure, ZONING ENG. SITE NO. or a certificate of Workers Compensation Insurance, or a certified copy thereof(Sec. 3800, Lab.C.L Policy Na Cmamm ❑ Certified copy is hereby funi ❑ Certified copy is Uled with the city inspection division. Applicant.V�_ �]�c MISC.- REFER TO ORD. FIRE SPRINK VE] N[] ENERGY T.Z4 VE] NE] PERMIT ISSUANCE 10.00 CERTIFICATE 017 EXEMPTION FROM WORKERS' FLOOD ZONE A.L.U.C. COMPENSATION INSURANCE section need not be completed pled if the permit is for one V E] N E] Y E] NE] PLG. CONTE. LIC, NO. PLG. TOTAL hundred hundred dollars(S100) or Ie,0 1 certify that in the performance of the work for which this per- mit is issued, I shall not employ any person in any manner so as to QTY. MECHANICAL PERMIT FEE FEE SUMMARY BUILDING /v JJ become subject to the Workers' CompensationpL,�aws of �Ca�li�fom�ia. Uaa'��plicunt �iSi 'i Ri!'05 NOTI .f. *_-_1 pp' If h I iS CL t etc o Pr- ALTER OR ADD TO MECH. 5.00 / APPLIANCE 5.00 PLAN CHECK FEE Q� emption, you should become subject to tire Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deenmd revoked. AIR HANDLING UNIT (TO 10MC.F.M.) 4.00 AIR HANDLING UNIT (OVER 10=C.F.M.) 6.00 SEISMIC FEE - CONSTRUCTION LENDING AGENCY I hereby afl'ion that there is a construction lending agency for the performance of the work for which this permit is issued ISec. 3097, Civ.C.L EXHAUST HOOD (WITH DUCT) 5.00 MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 Lender's Add c Lender's Addresses H EATI N G U N IT (OVER 100,000 B.T.U.) 9.50 ELECTRIC VENTILATION FAN (SINGLE) 4.00 I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and stale laws relating to building construction, and BOILER-COMP13 H.P. or 100,000 B.T.U.) 6.00 PLUMBING hereby authm-me representatives of this city to enter upon the aboti (veane nned property for inspection purposes. We) a c to save, indemnify and keep harmless the City of BOILER -COMP (Over 100,000 BTU) BEE FEE SCH. MECHANICAL MISC. - REFER TO ORD. Cupertino 9N Hat liabilities, judgments, costs and expenses which may in an uy .accrue against said City in consequence of the PERMIT ISSUANCE 10.00 CONST. TAX granting Of[ permit.- MECH. CONT, LIC. NO. MECH. TOTAL /^ TOTAL �J INSPECTOR COPY l.s