C9201 F APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 9201
ADDRESS
BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
OWN 'B PLAN CHECK VALIDATION
"AME ( 1iL� F �u- TV ELECTRIC PERMIT FEE
i' /
1`
NAME
THA TORS OUTLETS-SWITCHES-RECEP 10.00/1.00 �=
LIC.No. LIGHTING FIXTURES 10.00/1.00
1, CONTRACTORS
-4n-APPLIANCES-ADDRESS RESIDENTIAL 4.00
PRONE PANELS 18.00 DATE APPLICATION
OARCHITECT PANELS (OVER 200 AMP) 20,80
ENGINEEfl PLAN CHECKK FEE P.C.NO.
OR
/
uc.No. SIGNS TRANS. 3.00
A PERMIT VALIDATION
-,. ADDRESS ^ 1 _ SPECIALCIRCUIT 5.00
O JI..A@LJ SAI'v Jrtf TEMP.METER OR POLE INS. 20.00
v noxa SSTs MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
r o o LICENSED CON'T'RACTORS DECLARATION TEMP.POLE 30.00
a v I hereby affirm that 1 am licensed under provisions o-Chapter9 ISSUANCE DATE + t•
f y n (commencing with Section 7000)of Division 3 of the Business and
¢ BLDG. ELECT. PLG. MECH.
F i License Cla Code,and my license is in full force and effect �\
oZ y License Class hie.Number-
0
w t
Date Contmctor
¢ ¢ ¢ OWNER-BUILDER DfiCLARATION BUILDING PERMIT
o e- u INFORMATION
wg I hereby ul firm that I um exempt from the Contractor's License MISC.- REFER TO ORD
u_ 0< Law lin the following reason.(Svc.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 CL VALUATION $/FT.
Code:Any city or county which requires a permr to construct,alter,
QQ ¢ p Improve,demolish,Or repair any structure,prior 10 Its RAIa OCQ also ELEC.CONTE, r LIC.NO. ELEC. ('� Ono
a m M requires the applicant In,such permit to file a signed statement that Y TOTAL VY "I"MIT TO
a w the is licensed pursuant to the provisions of the Contractor's License
rzi Law(Chapter 9(commencingn'ith Section 7000)of Division 3 ofthe
¢ Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
ic I=-m lite basis for the alleged extruptlon.Any violation of Section 703I.5 1 iL`VdR`1E1I I 1 11
T
or by any applicant for a permit subjects the applicant too civil penalty
ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars fmy cin: D
,�-... ❑ has owner at the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 on- OCC.GROUP RES.UNITS
'r inter sole compensation,will(S fire work,and the structure a nut
intended or offered for rule (Sea 7044, Business and n of owner
os DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code'fht h o builds of License hltw dols not apply to an owner of
property who builds or wn eir ee thereon,and who docs such work FIXTURES-PER TRAP 5.00 W 50.FT.FLOOR AREA TOTAL ACREAGE
himself re of rote his own employees,Provided That such int building
mems are not intended or offered for sale.if,however,the building .GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner GAS-EA SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have lite burden of proving that he did not build or int- RES IND CON PB Omer
m prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with
licensed contractors 10 construct the Project(Seer 7044,Business LAWN SPRINKLERS-1 INC 5 V.8. 6.00 (/� ASSESSO ARCEL NO.
anJ Professions Coder The Contractor's License Law does not apply
to an owner of property who builds or improves thereon.unit who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant
Tho Contractor's License Law. to SEW ER-SANITARY-STORM EA.2001t110.00 Q (/\!
' TRACT NO. PARCEL NO.
x C1Ica,exempt under Sc,,-,R&P.C.Tor This WATER HEATER W/VENT 6.00
reason
sX Owner �,+ um f- WATER SYSTEM 5.00
E•+5 VALL ACC.DATE ACC.FILE NO.
W il $' SATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I hare a certificate ofconsenl to x9Ginsure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,La a.C.).
Policy No. Company - %
O ❑ Cerlifnedcopyishereby'fumished. z FIRESPRINK ENERGY T 24
' z Z ❑ Certified copy is filed with the city inspection division.
O Applicant / MISC.- REFER TO.ORD. LY � N❑ Y ❑ N�CC WCERTIFICATE 017 EXEMPTION FROM WORKERS• PERMIT ISSUANCE 10.00�Q OOO ZOrvE A. U.C.
LU > COMPF.NSAION'INSURANCE PLG.CONTE. LIC.NO: PLG.❑ [this section need not be completed if the permit is for one TOTAL N� V I N❑
Z hundred dollars IS 100)or less.)
U O I certify that in the performance of the work for which this per-'. QTY. MECHANICAL PERMIT EEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any manner so as to Y
O w become subject to The Workers Compensation Laws of California.
a Dater Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} w NOTICE TO APPLICANT: If,after making this Certificate of leodl
f- ? eruption,you should become subject to the Workers'Compensation ' APPLIAN 5.00 PLAN CHECK 'a
provisions of the Labor Code, you must forthwith comply with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 FEE
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10fMC.RM.) 6.00 SEISMIC FEE
1 hereby affirm that there is it construction lending ugcncy for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sere. MICROFILM
3097,Cie C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 PO
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 0'U/
Lender's Address ELECTRIC _
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• information is correct. I agree to comply with all city and county PLUMBING
ordinances and State laws relating to building construction, and BOILER-COMP(3H.P.or 100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000BTU)SEE FEESCH. 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 1000 f) CONST.TAX
may in any way accmc against said City in consequence .
of lite / ,i
gr. t of hisy�p��F99u�l. MECH.CONT. LIC.NO. MECH.
at ( :(BILI, p W&dr(r( TOTAL //}� TOTAL
SignSrinit' rFeWt-Appppb/cafnl/Contractor -�h /D'ale(" •z(L•'•',\/
INSPECTOR COPY
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