9408 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUDD
ARESSIL Ess
APPLICATION & PERMIT 9408
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
� YAALE
NAME `� - QTY. ELECTRIC PERMIT FEE
/ PHONE
NAME ACTOflS UTLETS- ITCHES-RECEP 10.00/1.00
LIC.NO. LIGHTING FISWXTURES 10.00/1.00
ADDRESS oa's APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
AARRCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO,
O
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ADDRESS ENG, SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
AooflEss
SERVICE CHANGE 20.00
0oo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a v w I hereby uflt nn that I urn licensed under provisions Of Chapter 9 ISSUANCE DATE
kommcmceg will,Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r y i Professions Colo,and my license is in(all lone and effect ❑ ❑ ® ❑
o 0 m o License Class Lic.Number
Date Conlmclnr
< a BUILDING PERMIT
¢ ¢ w a OWNIi R-BUILDER DECLARATION INFORMATION
R:
;LL I hereby rd inn that I um exempt from the Contractor's License MISC.- REFER TO ORD
F ri J Law for the following reason.(Sce,7031.5,Business and P ofussions PERMIT ISSUANCE VALUATION SIFT,
Codec.Any rnol or ,county which structure permit W co issuance,also
10.00
ins Ove,demolish,Otte air any structure, ELEC.CONTR. LIC.NO.' ELEC.
¢ a ¢ o pr p y nor n its issuance,also
O re lie is its thedp pursuant
fur sueh revisit to file a signed actor's nt thin TOTAL
n w m m he is licensed pursuant Ito the provisions of Iho Contractor's himnse PERMIT TO
r z a Law(Chapter 9(comnreneing with Section 7000)of Division 3 oftht � Cs
f i 0 Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢ r m the basis for[lie alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a ; _ by any applicant for a permit subjects circ applicant mu civil penalty ALTER-DRAIN -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 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or Offered for sale(Sec. 7044, Business and Professions
Code: ROOF,AREA,CON D. 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 - 50.FT,FLOOR AREA TOTAL ACREAGE
-P• himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.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 (EA) 200
builder will have the burden of proving that h -e did not build or im- - . . BUILDING USE
prove for purpose Of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB other
❑ I,as owner of the property,am exclusively contracting with El El El El Q
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractors License Law does not apply
to art owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contraclor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ len exempt under Sec..,B.&P.C.for this eWATER HEATER W/VENT 6.00
aon
xOwner WATER SYSTEM 5.00 ACC.DATE ACC.FILE N0.
WORK F-RS'COMPENSATION DIi -ARA'I'ION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate u(consent to self-insure,
Or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No. Cont party
oZ Z ❑ Certified copy is filed with the city inspection division. FIRE SPRINK ENERGY T-24
❑ Certified ropy is hereby furnished.
FO Applic:ml I MISC.- REFER TO ORD. YE] NEJ V ❑ N[:]
� w Cf:R'IIFICA'11:OF EXEMPT ION FROM WORKERS' PERMIT ISSUANCE 10.00 (J FLOOD ZONE A.L.LLC.
L MI'
�_ CO1:NSWION INSURANCE PLG.CONTR. LIC.NO. PLG. Y N❑ Y .. NE](T
d his section need not be completed it the permit is for one TOTAL S
Z hundred dollars 181001 or Ices.)
U O 1 certify that in the pe,I.UUanCC o1'the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
L F mit is issued,I sha11 not employ any person in any manner so as to
U become subject to do,War kurs'Contpensuliun Laws of Culil'ooma.
U a Dale Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>_ m NOTICE TO APPLICANT. it,after making this Certificate of Ex-
F Z emption,you should become subject to Ore Workcri Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, YOU Proud torlhwith comply with FEE
U such provisions or this permit shill be denied revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE
1 hereby affirm that there is a Construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work far which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Nene
Lendeh Address HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that l have read this application and stale that lire above VENTILATION FAN (SINGLE) 4.00
® ordinances n estate,. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000B.T.U.) 6.00 PLUMBING d v
ordinances and state laws relating t0 building construction, and
hereby authorize representativesofthis city to enter upon the BOILER-COMP(Over 100,000RTU)SEE FEE SCH, MECHANICAL
above-mentioned property tary spo fthi purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against Said City in consequence of the PERMIT ISSUANCE - 10.00
granting ofthis permit MECH.CONT. LIC.NO. MECH.
�- _ TOTAL TOTAL
Ig ala pplicant/Co true c Date
INSPECTOR COPY