9337 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATION _ PERMIT NUMBER BUILDING APPLICATION & PERMIT 9337
y
"^ a00RE55pp -
BUILDING —ELECTRICAL—PLUMBING—MECHANICAL
OWNER'S
�1 •� NAME I l PLAN CHECK VALIDATION
'SJ QTY. ELECTRIC PERMIT FEE
PHONE p1D
CONTRACTORS p
/h' rvamE UTLETS-SWITCHES-RECEP 10.00/1.00 F�
! 9 uc.No. LIGHTING FIXTURES 10.00/1.00
ADDRESS RRAcroFa
APPLIANCES-RESIDENTIAL 4.00
MAN oNE •.p PANELS 10.00 DATE KATION
oncm ECT PANELS (OVER 200 AMP) 20.00 FLAN F E P.c,No,
ENGINEER V
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG' SPECIAL CIRCUIT S.00 PERMIT VALIDATION
ADDRZIP EMP.METER OR POLE INS. 20.00
APPLICANTS
ADDDRESSDRESSMOTORS SEE FEE SCH.
SERVICE CHANGE - 20.00
WO LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
ri w 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DA
X a (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. G MECH.
F i Professions Code,and my license is in full force and ffec. ❑
2 O w� License Class_r3 Lie.Number
9 m I_ o Data�s-a f_ Contractor_
a m sBUILDING RMIT
¢ a OWNER-BUILDCR DEC,LARATI 3"
x ; LL IU- I hereby anion that I am exempt from the Contractor's License - MISC.— REFER TO ORD INFORM ION
w m VALUATION $/FT.
s- LL m j Law for the following rwson.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
m Code:Any city or county which requires a permit to construct,alter, -
¢ La ¢O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
C e, requires the applicant for such permit to file a signed statement that TOTAL ERMIT TO
u w$a he is licensed pursuant to the provisions of the Contractor's License
Hi> Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
fa Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
i o
¢ s- by basis for the alleged exemption.Any violation of Section malty STO IES TYPE CONSTR.
by any applicant fore permit d.Iltsthe$500).liwn❑oacivil penalty ALTER-DRAIN VENT•WATER (EA.) 5.00
of no[more than live hundred dollars(85001.1:
.❑ I,as owner of the property,or my employees with wages ns BACK FLOW PROTECT.DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 -
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve.
cents are not intended or offered for sale.If,however,the budding GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS EASYSTEM OVER 4 (EA.) 200
builder will have file burden of proving that he did not build or an. - . - . .
BUILDING USE
prove for purpose ofsale.)., INDUSTRIAL WASTE INTER3000 B IND CON Pe Omar
O . .
I,as owner of the property,am exclusively contracting with 13 El ❑ IDlicensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORSPARCEL NO.
and Professions Code; The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contracmAsl licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec.—,BAP.C.for this
reason WATER HEATER W/VENT 6.00
Owner Dale WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'C'OMPF.NSATION DIiCLARAT'ION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy themof(Sec.3800,Lab C.).
rl/ Policy No. Company
❑ Certified copy is hereby furnished. FIRE$PRINK ENERGY R44
Z 0 A plican tified copy is filed with dile city inspection division. Misc.- REFER TO ORD. V ❑ N❑ v ❑ NO
~ N_ PERMIT ISSUANCE 10,00
CC CIiR'fIPICA'1'li OF 1?XGMPTION PROM WORKERS' FLOODZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.N I PL
1 O (This section need not be completed if the permit is for one /✓G Y AL �O y❑ N❑ V ❑ N❑
Z hundred dollars(8100)or less.)
U O 1 certify that in the performance of the work for which this per. OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mil is issued. I shall not employ any Person in any manner so as to
OW becnm subset to h ,Wtrrkers' pensmion Laws ofC lit
a Uate '�!^VAtmlicarn BUILDING
} w NOTICE'1'b AI'I'LICANT: If,after making this Cartificute of li ALTER OR ADD TO MECH. 5.00
F Z eniplion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you mush forthwith comply with FEE
C..) such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=11RM-) '4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=1 .FM.) 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.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Audi HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county BOILER•COMPO H.P.or 100,000 B.T.U.) 6.00 PLUMBING
on inances and state laws relating to building construction, and
s hereby authorize representatives for
of this city to enter upon the BOILER-COMP Miser 100.000 BTU)SEE FEESCH. MECHANICAL
above-mentioned property forinspofth i purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, casts and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
granting f permit' MECH.CONT. LIS.NO. MECH.
TOTAL TOTAL
Signature o Applicant/Contract Uate^ 1/ h
OFFICE COPY