9336 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ,
BUILDING PROJECT I IDENTIFICATION _ FERMITNUMBER
BUILDING APPLICATION & PERMIT
ADDREI r0 II ��v% \U♦ L
2-- ,V�W'r�✓^x-� - BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 9336
OWNER'S 1 }rwr L j,s. ;^ hA+ +* 9t+h 4Ti �, C -{� PLAN CHECK VALIDATION
'l' NAME' G CITY. K )g '' - ELECTRIC PERMIT
G PH ONE
CONTRAOTOR'S
•� NAME �. OUTLETS`-SWITCHES-RECEP 10.00/1.00
UC NO. 13 �� LIGHTING FIXTURES 10.00/1.00
CIN "I PPLIANCES-RESIDENTIAL 4.00
.�. ADDRESS x �ylr n�` r
1
( Q' (f4, VU �iJe PHONE /2u-I_yI PANELS 10.00 DATE OF APPLICATION
ARRCHITECT PANELS(OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
O
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRESS ENG, PERMIT
CIRCUIT 5.00 PERMIT VALIDATION
zlv EMP.METER OR POLE INS. 20.00 V '"
ANT'a
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 //S/
w o 2 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 /Y G
¢ i w 1 thereby affirm That I am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and
y¢n BLDG. ELECT. PLG. MECH.
2 Professions Code,an my license is in full force etf ./_ II�Y-IIS
i vi D License Cl _ Lic.Number J W
m 1- Date Contractor
' n¢a - OWNER UILDER DECLARATION BUIL01NG'PERMIT,4.,[;�.d
c ic U B :t, ;'INFORMATIONP,xE?�p,,Y,�e•,
3
I- 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
1 w VALUATION $/FT.
uoa Lad.oAnyeity owiounty which requires
5.a perminess t to
Professions PERMIT ISSUANCE 10.00
- yam Code: e,decoy sh counpair any structurep prior to construct.alter,
5 ¢ 0 ImprpY0.demolish,or repair any structure,prior to its issuance,a150 ELEC.CONTR. LIC.NO. ELEC.
O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
E
$ he is licensed pursuant to the provisions of the Contractor's License n
HZi Law(Chapter 9(commencing with Section 7000)of Division 3 of thea �p1fa +.zqn `- L
E 4 o Business and Professions Code)or that he is exempt therefrom and QTY Ty tt mPLUMBING PERMIT -+ FEE yq
¢ 1-g the basic for the alleged exemption.Any violation Df Section 7031$ Pa„ ,.,tF,.,5 YY_ tv.� „-Qy 4#'t y., a f +:,,L;{a"b-','`C' STORIES TYPE CONSTR.
d ; by any applicant for a perm it subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(S 5001.):
-❑ I,as owner of the property,or my employees with wages asBACK 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 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 SM FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
memsarenotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-1 1 NC.4 OUTLETS 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 the burden of proving that he did not build or hn- RES IND CON PB Colon,
for Purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ L th
as owner of the property, exclusively contracting with
licensed contractors to construct the
project(Sec.7044,BusinessLAWN SPRINKLERS-i INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to anowner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contrtrador(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ftl3B.A0 WP7ACC.DATE
PARCEL NO.
❑ lam exempt under Sec..,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM PA 5.00
ACC.FILE NO.
W'ORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate ofconsent to self-insure, vt 7 or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
COPY thereof(Sec.3800,Lab.CJ. i}s�Polity No. Company T�'e�1L�7C'f "if0 ❑ Certified copy is hereby fume ed CIt 01 uver Ino ENERGY T44
Z ❑ Certified Ael�,.is filed i[ the c' inspection division. MISC.- R RTOApplicant 122 Iu91_ Y 0 N❑
= N CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT-ISSUANCE FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Q'p ❑ ❑
CL O (This section need not be completed if the permit is for one TOTAL Y N Y N
Z hundred dollars(SIO(lor less.)
0 O1 certify that in the performance of the work for which this per, r•+ t i `' ° f"`` 2- .�� FEE SUMMARY �, .4t0
QTY -' MECHANICAL PERMIT FEE .
LL F- mit is Issued,I shall not employ any person in any manner so as to !'.
0 W become subject to the Workers'Com pensa tion Laws of California BUILDING
n
Date-Applicant ALTER OR ADD TO MECH. 5.00
} Z NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F zmption,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 10,00DC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER I0,000C.F.M.) 6.00 SEISMIC FEE
I hereby affirin that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the 3097 performance of the work for which this Permit is issued(Sec, HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name
Lender's Address HEATI NG UN IT(OV ER 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
a dinancis n Correa.I agree to
comply with all city and county BOILER-COMP(3 H.P.Dr 100,000 B.T.U.) 6.00 PLUMBING /
ordinances and state laws relating to building construction, and
hereby authorize representatives ec This city to enter upon 111e BOI LER-COMP hover 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 any way accrue ag insl said City in consequence of the
seenl/ip(��Mn,n I. MECH.CONT. LIC.NO. MECH.
N[. e.� G I ZZ--OV` TOTAL
TOTAL;-,
Signature ol'Applicant/conumchisr Date
OFFICE COPY