9350 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY 1
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING y APPLICATION & PERMIT
D _D
ADDRESS ~r PQr{IN 9350
^/\ BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OW NE 's PLAN CHECK VALIDATION
NAME (400) OTY. ELECTRIC PERMIT FEE
TO JJAJ _S PHONE ZS-O
croR's
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME
LIC.NO, - LIGHTING FIXTURES 10-0041.00 rN
ADREScrURs
DPPLIANCES-RESIDENTIAL 4.00
CONTRA
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECTPLAN CHECK FEE P.C.NO. ,
OR
PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.No, SIGNS TRANS. 3.00 PA1
naoeess eco SPECIAL CIRCUIT 5,00 II?ERMIT VALIDATION
zlv EMP.METER OR POLE INS. 20.00 JUL 2 a 7985
APPLICANT ss MOTORS SEE FEE SCH.
ADDREES C1(y of Cope
SERVICE CHANGE 20.00 �/no
o O INCENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
Ix v I hereby affirm that I am licensed under provisions of Chapter 9 J ISSUANCE DATE
wz w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT PLG. MECH.
H m z Professions Code,and my license Is in full force and effect. ❑ ❑
z 0 w - License Class Lic.Number
HF 0 Date Contractor
a inw ¢ OWNER-BUILDER DECLARA'f10N BUILDING
INFORMAT 10%1T
D n U MISC.- REFER TO ORD
K
3: 1 0 H I hereby affirm that I mm exempt from the Contractor's License VALUATION $/FT.
LLOa Law for the ity owingreeson.(h requiJla permit
erm5. it to
Professions PERMIT ISSUANCE 1.(1100
r u, Code: e,dem y demolish,
cor n pair any structure p riot t o is issuance.
also
QQ 40 IlllplDVe,demDhrM1,Ol repair any structure,prior to dr lrrOanCe.aI50 ELEC.CONTR. LIC NO. ELEC.
-O u requires the applicant for such permit to file a signed statement that TOTAL V� PERMIT TO
w$ he is licensed pursuant to the provisions of the Contractor's License
Fzi Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
0 , the basis for the alleged exemption.Any violation of Section 7031.5 1 TVPNS R.
a3 � byanyapplicant lin a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCG GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered 1'or 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 -
propertywhobuildsorimprovesthereon,and who docs Such work FIXTURES-PER TRAP 5.00 SD.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00
or improvement is sold within one year if completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or int- BUILDING USE
prone for purpose of sale.). ES INDUSTRIAL WASTE INTER. 30.00 IND CON Pa other
❑ 1,as owner of the property,an,exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors tD construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 071 ASSESSORS PARCEL 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 eontractorls)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contract rsp1have
TRACT NO, PARCEL NO.IP
r` ❑ Ia tr nm ,B.&P.C.for this WATER HEATER W/VENT 6.00
rear�Qn
/ OwHsr; Date WATER SYSTEM 5.00 ACC.DATE ACG FILE NO,
WORKATION DECLARATION WATER TREATING EQUIP. 5.00
eereby affircertificate ofconsent to self-insure' ZONINGENG.SITE N0.
or a certificate of Workers'Compensation Insurance or a certified
copy thereoflSec.3800,Lab.C.L
Policy No. Company
O Q--Ccrtlfetl copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z 2rf❑ Certified copy is rile tl with thlf city inspuctinn division.
O Applicun't� MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
~' wFLooD zorvE A.L.u,c.
PERMIT ISSUANCE 113.00
��-
CERTIFICATE OF Ex Eh1RTION FROM WORKERS' ..
CL
W 7� ------ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. 0-C,Z ' _TI N, section need not be completed if[hY[lie is for one TOTAL (� �' E] N❑ Y ❑ N❑
hundfeB dollars IS 100)or Tess.)
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
U. F mit is issued,I shall not employ any person in any manner so as to
Ow become subject to the Workers'Compensation Laws of California. BUILDING
a Date-Applicant ALTER OR ADD TO MECH: 5.00
DO NO'I'ICIi '1'0 APPLICANT: If,after...A,ag this Certificate of Ex- -
F" ? cllpUmn,you should become subject In the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the labor Code, you most I..thwith comply with FEE
U such provisions or this permit shall be deemed revoked. r AIR HANDLING UNIT(TO 10=QF.M,) 4.00
CONSTRUCTION LENDING AGENCY 1 'AIR HANDLING UNIT(OVER IOPMC.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there ji, construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Ci,.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
LendName
e
Lender's NamAddress HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I 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 d71
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 RTU)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 umd expenses which CONST.TAX
may in any way aC against said City in consequence of the PERMIT ISSUANCE 10.00
granti this pen It, ECH.CONT. LIG NO. MECH.
TOTAL
2(G TOTAL ov Ov
v\ Sig or of Appl Cant/ o Ua[
\ INSPECTOR COPY
i