9345 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
aDILmNG APPLICATION & PERMIT
9345
ADDRESS BUILDING—ELECTRICAL—PLUMBING—MECHANICAL
0 o F
OWNER'S PLAN CHECK VALIDATION
NAME �/�N/v yS PHONE
OTY. ELECTRIC PERMIT FEE
CONT✓ C GO
croRs
NAME UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
/� yJrFi/1JS//yCuc.No.�o.2GZ-s LIGHTING FIXTURES 10.00/1.00
L
CONTRACTOR'sRESS PPLIANCES-RESIDENTIAL 4.00
e1 / $,TOCli,rV 114 kePHONE�.a v-/66L PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO,
O
OR
ENGINEER 6�
LIC.No. SIGNS TRANS. 3.00
ARCH.OR END, SPECIAL CIRCUIT S.QQ PER MIT VALI DATION
ADDRESS
�l ^
zIP rrEMP.METER OR POLE INS. 20.00
APPLICANT's MOTORS SEE FEE SCH.
ADDRESS E55
- SERVICE CHANGE 20.00
w O o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 / J-3/p j
a I hereby a(linn that 1 um licensed under provisions of Chapter 9 ISSUA CE DATE
N a N (Commencing wish Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H N z Professions C Jc a it my license is in full for and fepL� ❑ ❑ r-1
License a Lie Nu bei'
4 z w Ualc C< Contractor
a y f BUILDING PERMIT
in OWNHR-BUILDER DECLARATION INFORMATION
w 3 LL y 1 hereby affirm lint 1 am exempt from the Contractor's License MISC.— REFER TO ORD
i.oa Law for the followingreasoa.(Sec.7031.5.Businessand Professions
PERMIT ISSUANCE 10.00 VALUATION $/FT.
� - Code:Any city or county which requires.permit toconstruct,alter,
Q ¢ ¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
ce
D u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
a w m he is licensed pursuant to the provisions of the Contractor's License
Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe �L,B(j-- W—Mech/�
a Business and Professions Code)or that he is exempt therefrom and- PLUMBING PERMIT FEE
c the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
u ;m by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(S500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 oce.GROUP RES.UNITS
their Sale compensation,will do the work,and the structure is not
intended or offered for sale (Sc,. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND.
VIC-
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 — SD.FT.FLOOR AREA TOTAL ACREAGE
himself re of rote his own employees,provided lhnl such improve-
hients a through
ugh des oroffered employee sale.If, that such
building GAS-EA.SYSTEM-11NC.40UTLETS 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 im- RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct Ili, project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 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(E 9.®
contracts for such projects with a contractons)licensed pursuant In SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ I am exempt under Sec.—,B.&P.C.for this WATER HEATERW/VENT 6100
rCll[on
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK FRS'COMPF-NSATION DECLARATION WATER TREATING EQUIP. roty of &Wr11f1O
1 hereby affirm first 1 have a certificate of consent to self-insure•. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy therco 1 3 00,Lab.0
Policy N -mopuny
Q ❑ Certified copy is hereby furnished FIRE SPRINK ENERGY T 24
Z Z ❑ Cenil'ic by is til or, L O city inspection division. MISC.- REFER TO ORD.
O ApplicCc Y❑ N❑ Y ❑ N❑
Fy PERMIT ISSUANCE t— FLOOD ZONE A.L.uc.
Lu CIiRTII'ICCOM F SAIi ION INS FROM WORKIiRS'
CL >_ Ce(] not be completed
RANGE PLG,CONTR. uc.NO. PLG. Y❑ N❑ Y ❑ N❑
CL O 1'I'his section need not be completed i(the pcnnit is for one TOTAL �
::) Z hundred dollars IS 100)or lass.)
U O 1 artily that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H 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
y Datc Applicant ALTER OR ADD TO MECH. 5.00
} to NOTICE TO APPLICANT: IL after making this Certificate of Ex-
f— 2 emption,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=CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction leading agency for EXHAUST HOOD WITHPWfh 5.00
the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.C.).
Lender's Name HEATING UNIT IDV 00'000 B.T.U!19.50 ELECTRIC
Leader's Address _
I Certify that I have read this application and slate that the above VENTILATION FAN (SING LES 4.00
information is correct.I agree to comply with all city and county PLUMBING
ordinances and state lows relating to building construction, and BOILER-COMP(3 H.P. 6.00
hereby authorize representatives of this city lD enter upon the '1 O �S+
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL aC.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupn]ino against liabilities,judg...Cox, costs and expenses whichCONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
gratin flh ispan fL MECH.CONT. LIC.NO. MECH. µ
J TorAL �Z /46
0 — TOTAL
ignalureof pplicant/Contractor Ualc
OFFICE COPY \
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENT[FICATION PERMIT NUMBER
SO,LO,NG APPLICATION & PERMIT
ADP RESs
BUILDING-ELECTRICAL-PLUMBING-MECHANICALAr 9345
PLAN CHECK VALIDATION
k NAME OTY. ELECTRIC PERMIT FEE
e1 r1V1V V S cu PRONE
1
NAME OUTLETS UTLETS-SWITCHES-RECEP 10.00/1.00
/i" bCLIC.NO. LIGHTING FIXTURES 10.00/1.00
ADDRESS
.DpRs APPLIANCES-RESIDENTIAL 4.00
ness
o`F 1 N -PRONE 2,90-144 PANELS 10,00 DATE OF APPLICATION
ARCHtTECi PLAN CHECK FEE P.C.NO.
' OR PANELS (OVER 200 AMP) 20.00
ENGINEER
uc.rvo. SIGNS TRANS. 3.00
ADDRESS ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
�r ZIP EMP.METER OR POLE INS. 20.00
APPLICANT MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 /
'00 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 7/�,
a u v I hereby affirm that I am licen3ed under provisions of Chapter 9 ISSUANCC//E DATE
N <w (cmnraimsing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H D z I'mfes'sions Code,and my license is in full force and effect
O ❑ ❑ ^
z ve - License Clas Lie.Number..
9 D.. / 2 ContractorM
-w
Y E J /` r BUILDING PERMIT
¢ ¢ or c OWNER-BUILDER DECLARATION
o A O MISC.- REFER TO ORD INFORMATION
X ; y I hereby affirm that I am exempt from the Contactor's License
a_ s, Law for the following reaso..ISce.7031.5,Bc,incssemd Professions pERMIT ISSUANCE 10.00 VALUATION $/FT.
� - Code:Any city or county which requiresu permit to construct,alter,
Qp Q 2 improve,demolish,or repair any structure,prior to Its issuance,also ELEC.CONTE. LIC.NO. I ELEC.
u w m¢� requires the applicant for such permit to file a signed statement that 1 TOTAL PERMIT TO
he is licensed pursuant to the provisions of the Contractor.License
i Law(Chapter 9(commencimg with Section 7000)o f Division Sof Bm II
Eio Business and Protussions Code)or that he is exempt therefrom and. GT-Y: PLUMBING PERMIT FEE L 8 c- -- ~c
DE C, the basis forthealleged exemption.Any violation of Section703L5 1 STORIES TYPE CONSTR.
a _ by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
rf no[more than five hundred billars(5500)):
❑ 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 (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND, 5.00 r!x'
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 5.006'��— 50,FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees.provided that such improve- r.
mems are not intended or offered for sale.If,however.the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6,00
or improvement is sold within one year of completion, the owner- GAS EASYSTEM-OVER 4(EA) 200
bu i ldcr will have the burden of proving that h - . .
e did not build or un- 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 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 Contractor's License Law does riot 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 it contmctons)licensed pursuant to -
meContractor'sLicenseLaw. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCELNO.
❑ lam exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
1
Owner Date WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of conwat to self-insure ZONING'
or a certificate of Workers'Compensation Insurance,or a certified ! (ENG.SITE NO.
copy thereof ISec.3800.Lab.C. �i ,
Policy Np� i ompany s
0 ❑ Ce/fI i 1,ishereby rnnlcd. FIRE SPRINK
a ENERGY T-R4
z Z _ ❑ CertifiedCoty is filed fli if city inspection division. MISC.- REFER TO ORD. 11 zr
G ) Applicant Y ❑` N❑" Y ❑ N❑
CC C: TIFICrrf EXEMPTION FROM WORKERS' PERMIT ISSUANCE 1 r/'[. FLOODZONE A1.UC.
L COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL 0 1'ILis section need not be completed if the permit is for one TOTAL Y❑ NE] Y ❑ N❑
D Z hundred dollars IS 100)or less.)
U 0 I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
L 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
y Dar° Appl'emit ALTER OR ADD TO MECH. 5.00
)F to NO I'ICI: 'I O,APPIACANI: If at making this Certificate of 1:x-
F ? unption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you.muet forthwith comply with FEE
CJ such provisions or this permit shall be deemed-revoker. AIR HANDLING UNIT(TO 10,00DC.F.M.) 4.00 -
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 ,. SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
theeperformance r MICROFILM
orance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATI NG UNIT(OVER 100,000 B.T.1-119.50 ELECTRIC
I certily that I have .it this application and state that the above VENTILATION FAN (SINGLE) 4.00 V
information is correct I agree to comply with all city and county PLUMBING 0 i
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 O'L'
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. p. MECHANICAL .2o
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. M
Cupertino against liabilities,judgments, cost0and expenses which PERMIT ISSUANCE 1000 w CONST.TAX
may in any way accrue against said City in consequence of the /U
' granting of this permit MECH.CONT. LIC.NO. MECH.
J / TOTAL 0,2_0 _ TOTAL J3 w
gnatureof 1 ant/Contractor ale /
INSPECTOR COPY