9437 1 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
I� "'•._ BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
APPLICATION & PERMIT
BUILDING _ 9432
ADDRESSm`� �o To
rr L4- BUILDING- ELECTRICAL-PLUMBING-MECHANICAL
lOH
E'S - PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
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PHONE
.corvrRAcroas
ME OUTLETS-SWITCHES-RECEP 10.00/1.00
NA
An Ir ray- V.e,I r ,E.No LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S APPLIANCES-RESIDENTIAL -4.o0
ADDRESS /
/oaol4/*qp P. ` ` Of� PANELS 10.00 DATE ofAPPucnnoN
ARCHITECTPANELS (OVER 200 AMP) 20.00ENGIPLAN CHECK FEE P.C.NO.
OR
O
NEER
' uc.No. SIGNS TRANS. 3.00 '
ADDRESS ENC' SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
APPLICANT'S
ADDRESS MOTORS SEE FEE SCH.
SERV.POLECHANGE 20.00 C� AV46 R
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 (_]p� y I q�
¢ u 1 hereby affirm that I am licensed under provisionscf Chapter 9 - 155 ANCE.ATE I'1
m G y (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r mz Professions Code,and my license is in full force and effect. ❑ ❑ �.• ❑
z o m - License Class Lic.Number
C)C) ,, r Date Contractor T -
¢ m s .� , BUILDING PERMIT
¢ ¢ w ¢ OWNE;R-BUILDER DECL RATION -
INFORMATION
o A MISC.- ' , - REFER TO ORD
wac u H I hereby affirm that I ant exempt from the Contractor's License
u_ o`� Law for the following reuron.(Sec.703 L5,Business and Professions PERMIT ISSUANCE a 10.00 vnwnnoN $/FT.
-' Code.Any city or county which requiresa permit toconstrct,alter,
tt ¢ ¢ 0 improve,demolish,or repair any structure,prior to i[s is atice,also ELEC.GONER. LIC.NO ELEC.
o¢ requires the applicant for Such permit to file a signed slI ement that TOTAL PERMIT TO
d w ee m he is licensed pursuant to the provisions of the Conln�'ru s Lieense
Law(Chapter 9(commeneingwilh Section]OOO)oCDi 'sion 3 of the /�IUVC .� rQULTVBE
¢ Business and Professions Code)or that he is exempt t retront and QTY. PLUMBING PERMIT FEE T
¢ F o the basis for the alleged exemption.Any violation oC Se 'on 7031.5 1 STORIES TYPE CONSTR.
by any applicant fora permit subjeatsthu applicantto a c vil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
"j of not more than five hundred dollars($500L)
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.SHOUP RES.UNITS
their sole 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- 5.00
Code:The Contra cloi s License Law does not apply to an owner of
i" property who builds or improves thereon,and who does such work FIXTURES-PER TRAP Ir 5.00 SO.ET.FLOORAREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
sarenotintendedoroffered-for sale.If,however,the building GAS-EA.SYSTEM-1U/TLETS 1NC.406.00 a
4
orcminlprovement is sold within one year of completion, the owner- x
builder will have the burden of proving that he did not build or am- GAS-EA.SYSTEM-OVER 4(EA.) 2.00,' BUILDING USE -
prove for purpose otsale,). - INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ [,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.60 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's-License Law does not apply -
- hr an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a cnotracmrts)licensed pursuant to
III,Contractor's Lie anse Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. I PARCEL NO.
D 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.
WORK Ii RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
_ I hereby affirm that 1 have a certificate of consent to self-insure.
>� or a certificate of Workers'Compensation Insurance,Or a certified ZONING ENG.SITE NO.
copy thereof(See.3800,Lab.C.L y l
:ire Policy No. CmEPan} $?!!4 f..F" C .
C) ❑ Certified co is hereby mnu L FIRE SPRINK ENERGY T 24
Z A❑h Certified py . id with the 'it specter division
- MISC.- REFER TO ORD. y N Y N
❑ ❑ ❑ ❑
� W c iIFICATF,01'EXEMP' ON PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.II.C,
LU-> COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O 1 his section need not be completed if the permit is for one TOTAL YE] N❑ Y ❑ N❑
:) Z hundred dollars($100)or less.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H hill is issued,I shall not employ any person in any manner so as 10
U becomesuhject to the WorkcD'Compensmion l-awsof California.
U a Uute Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE"TO APPLICANT: If.after making tllis Certificate of Es-
Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply will FEE
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10)000C-F.M.) 4.00
CONSTRUCTION LENDING AGENCY Is, AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the
pedrunt3097, ,nve of the work for which this permit is issued(Sec. HEATING UNIT(70100,000 B.T.U.) 8.00 MICROFILM
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
Icertify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct I agree to comply with ell city and county PLUMBING
ordinances and slate laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 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,j ents, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX '
may in any y accrue ain list said City in consequence of the
granting of
per iL MECH.CONT. LIC.NO. MECH.
OTAL TOTAL
Slgnat of Applicant/Contractor Uale
INSPECTOR COPY