9437 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LD1 NG CT I DENTI FICATION - PERMIT NUMBER
BDILDING7�,
ADDREss PROJEA2,qe7-oAPPLICATION & PERMIT 9437
0GO EAj, �3a L.4- ,� BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
O ,i Re PLAN CHECK VALIDATION
T NAME QTY. ELECTRIC PERMIT FEE
GO /. � _&7 PRONE
CONTRACTORS OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME
LIC.NCyf ;Z LIGHTING FIXTURES 10.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADDRESS 44,��
/09 ,,417,4
�vy .ON/� �•�as PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
O
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH,OR ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDRESS rl� .
ZIP TEMP.METER OR POLE INS. 20.00 1 p
ADDRESS MOTORS SEE FEE S.C.H. /Lgp�s.a�Y LJIO ^
ADDRESS `"�(A�/'''��__
SERVICE CHANGE 20.00
,1
o o TEMP.POLE 30.00 LICENSED CONTRACTORS DECLARATION -D •1- I Au(!*
a u 0 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
H< w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H N z 1'mfasions Code and m li rose is in full force and effect ❑ ❑ ❑ ❑
z O m - Liccns• las r' Lic.Numb
_.Z
o F ° nam ^ _ Contractor .BUILDING PERMIT
E a w u OWNER-BUILDER DECLARATION INFORMATION
3 LL m 1 hereby al fum (hat 1 am exempt from the Contractor's License MISC.- REFER TO ORD
LL o vs Law for the following reason.(Sec.7031.5,Business.bd Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
� - Code:Any city or county which requires a permit to conslrud,Iter,
Qar< 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR, LIC.NO. ELEC.
° u requires the applicant for such permit to lite a Signed statement that TOTAL PERMIT TO
d w m he is licensed pursuant to the provisions of the Contractor's License
F z i Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe MOVE .�TR 0CrrcieC:
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
2 °o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
carAte - by any applicant fora permit subjects the applicant toa<ivil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not mora than five hundred dollars(8500).).
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEVICE 4.00
OCC.GROUP RES.UNITS
their sole compensation,will work, the structure is not
intended or Offered for sale (Sec.c. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code The Contractor's improve Law docs nn1 apply to an owner of
property who builds or improves employees.
thereon,and who Anus such work FIXTURES-PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE
himself re of rote his own Cmred fors, le.if.cJ that such improve-
mcldsarenotintcmdcdor withiproneyeaale.Icomplevcq the building GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
Ely improvement is sold within one year of completionthe owner- GAS-EASYSTEM-OVER 4 (EA) 200 BUILDING USE
builder will have the burden of proving that he did not build or inn- . . .
- RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ 0 ❑ ❑
❑licensed as owner of the property,he exclusively . 7044, ins with
adPro contractors to construct the project(Sec. 7094,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL N0.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves Otercon,and whoLAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contructurfsl licensed pursuant m
SEWER-SANITAR V-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
TIC Contractor's License Law.
❑ lam exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKF.RS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
1 hereby infirm that I have a certificate of const ll m set-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a cerlil'ied
Copy thereof(Sec.3800.Lab.C.l.
Policy Nn. Company�.f_?:L`Y F{.0 34Q
O ❑ Certified islerchy r shed. FIRE SPRINK ENERGY T-24
ZZ ❑ Certifi• p s ion spcction division MISC.- REFER TO ORD. Y � N� Y ❑ NE)
O APPlicanl o '
CC w :RTI FICATE OF EXEbI ION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C.
Lu >_ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL 0 (This Section need not be completed if the permit is for one TOTAL Y❑ NY C3 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 FEE FEE SUMMARY
LL H mit is issued:1 shall not employ any person in any manner so as to
Q W become subject to the Workers'Compensminn laws of California. BUILDING tO
Date Applicant ALTER OR ADD TO MECH. 5.00
} tram NOTICE TO APPLICANT: If,after making this Certificate of Ex-
f" ? Inaption,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)000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=CF.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certify that I VENTILATION FAN (SINGLE) 4.00
information is correct.1 agree to comply with all city and county BOILER-713 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorim representatives of this city to enter upon the BOI LER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree In save, indem and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities, d vents, costs and expenses which CONST.TAX
may in any y accrue ag'Inst said City in consequence of the PERMIT ISSUANCE 10.00
gruntingo pe MECH.CONT. LIC.NO. MECH.
g_ S TOTAL TOTAL
Signat uof Applicant/Contraeto Date
OFFICE COPY