9235 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FI CATION PERMIT NUMBER
aNLDING APPLICATION & PERMIT 9235
ADDRESS
vlTic OI BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME ftIOAE DE I,Hitl 72'i F122/4 QTY. ELECTRIC PERMIT FEE
PHONE
CONTRACTORS CTORS
NAME
rvnME OUTLETS-SWITCHES-RECEP 10.00/1.00
Ot3(6N 1 11b A LIC.NO.�I "Z LIGHTING FIXTURES 10.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL .{ 4.00 UU
ADDRESS 10057 (MBb1Z(0i PvE
PHONE PANELS 10.00 r DATE OF APPLICATION
RR (TETPM`T PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER '
LIC.No. SIGNS TRANS. 3.00
moo ESS ema. SPECIAL CIRCUIT 5.QQ PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 2000.
�
ANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
02 LICIiN$IiU CONTRACTORS DECLARATIOM1'
TEMP.POLE 30.00
a v 1 hereby affirm that I am licensed under provisions of Chapter 9 i r u _ oti ISSUANCE DATE
w¢ w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r N z Professions Code,and y license is in full force and effect 177t ❑ ❑ ❑
2 o w - License Class Li P`Nwnber
4 m w Datelf�oContractor
a m s I BUILDING PERMIT
¢ ¢ IT
OWNI:R-BUILDER DECLARATION INFORMATION
w S o a 1 hereby affirm that I am exemp t from the Contractor's License MISC.- REFER TO ORD
u I-m y VALUATION
FLLoa Law for the ityfollowing ress n.whichc.703 uires a perBusmness it
tocnd Professions PERMIT ISSUANCE. 10-M ryL
Code:Any city or county which requirese permit In construct alter,
QQ 4 0 improve,demolish.Or rl'palr'dn}'structure,Ule.prior IO IIS issuance.'1511 ELEC.CONTR. LIC.NO. ELEC. _rf (/1/
LL requires the applicant for such permit to file a signed statement that TOTAL G . PERMIT TO
n w m lie is licensed pursuant to the provisions of the Contractor's License
H z a Law(Chapter 9(commencing with Section 7000)of Division 3 of the7R. e�
4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ H e the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
ate _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than live hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole Compensation,will do the work,and the Structure Is not OCC.GROUP RES.UNITS
intended or offered Do sale (Sc,:7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CON D. 5.00
Code:The Contractors License Law does not apply to an owner of
property who build;`or'improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.PT.FLOOR AREA TOTAL ACREAGE
himself re through his-own offered
fors,provided that such ibuildi rove-
taunts are orempldforsale,provided
the building GAS-EA.SVSTEM-11NC.40UTLET$ 6.00
or improvement Is suld within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that lie did not build or in, GAS USE
prove for purpose of sale.). INDSTRIAL WASTE INTER. 30.00 RES IND CON PB Dmer
❑ I,as owner of the property,am exclusively contracting wiINDUSTRIAL ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7144,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:'rhe 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 contractoo,)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
Ilse Contractors License Law. TRACT NO, PARCEL NO.
❑ I am 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 N0.
W'ORKERS'COMPEN'SATION DECLARATION 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 lhereoflSec.3800,Lab.C.L
Policy No. Company
Cl Certified co yrs hcrebyf !D� ce. FIRE SPRINK ENERGYT24
Z, Z ❑ Certified o y is tiled s i 1 One city inspection division. MISC.- REFER TO ORD.
O Applicant v ❑ N❑ V ❑ N❑
VV
0: N CI:Rl CA'I'EOP FxlE Pl'I0 ROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C.
LU > COMPI:NSA'I ION IN RANCE PLG.CONTR. LIC.NO. PLG.
0 (This 'eatiiin ored not be completed if the pcnnit is for ane TOTAL V❑ N❑ V❑ N❑
Z hundred dollars(S100)or less.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
U- F mil is issued,I 'hull not employ any person in any manner so as to
_ Uw become subject to the Wnrkels'Compensation Laws of California
WDate Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE 'r0 APPLIC'ANI': If,after making this Certificate of Ex-
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 strait be deemed revoked AIR HANDLING UNIT(TO 10=12-F.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 lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the
3097,Gv
eMICROFILM
performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lenders Name-
Lender's
ame HEATING UN IT(OVER 100,000 B.T.U.)9.50 GC.
Lender'sName-s ELECTRIC
I certify that l have read this application and state that the above VENTI LATION FAN (SING LE) 4.00
• information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
Hereby in boric representatives of this city to enter upon the BOILER-COMP (Over IW,DOOBTUISEE FEESCH. MECHANICAL
abovomentioned 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 amen against said City in consequence of the
granting h pcnnitMECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Sign' c I. PPI cantlCo ract ale
INSPECTOR COPY