9238 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON PERMIT NUMBER
BUILDIrvG APPLICATION & PERMIT 9238
ADDRESS OC/
BUILDING—ELECTRICAL—PLUMBING—MECHANICAL
OWNE 'S PLAN CHECK VALIDATION
NAME 'd
® E C/ C/ QTY. ELECTRIC PERMIT FEE
d V
T ACTOR
UTLETS-SWITCHES-RECEP 10.00/1.00oo"e
NAG LIGHTING FIXTURES 10.00/1.00
RRcs V
ADDRESS APPLIANCES-RESIDENTIAL 4.00
g `
iii PANELS 10.00 DATE OF APPLICATION
AR C ��L—C PLAN CHECK FEE P.O.NO.
OR / //((0 PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.NO, SIGNS TRANS. 3.00
ADDREss END' SPECIAL CIRCUIT 5,08 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
AI MOTORS SEE FEE SCH.
ADDROOR Ess ss SERVICE CHANGE 20.00 •7/j�
0 0 o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 5
Q U w 1 hereby affirm that 1 am licensed under provisions of-Chapter 9 ISSUANCE DATE
m c y (Commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r w z Professions Code d y license is in full force and effect. ❑ ❑ ❑
2,0 m — Licenu Class _Lia Number
0 Z^ H 0/ Dare 7 f Contractor
H `— — �'rL�T l--'
a x ' BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DECLARATION
o a D ) INFORMATION
A
w 3 u. r 1 hereby a(tirm that I am exempt from the Contractor's License MISC.— REFER TO ORD
u O j Law for the following reason.(Sec.703 L5,Business and I'mfessimts VALUATION $/FT.
— PERMIT ISSUANCE 10.00
Code:Any City or county which requires permit to construct,aper,
CE to Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC.
0 LL requires the applicant for such permit to file a signed statement that ' TOTAL
a w w he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
H s- Law(Chapter 9(commencing with Section 7000)of Division 3 attire J�
io Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE ALUMJ!NC
¢ F m the basis for the alleged exemption.Any violation O(Section 7031.5 !� STORIES TYPE CONSTR.
d3 •- 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(5500).):
❑ 1,as owner of Om property,or my employees with wages as BACKFLOW PROTECT.DEV ICE 4.00 OCC.GROUP RES.UNITS
sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. ,5,00 W
Code,The Contractors License Law dues not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5^00 ISO.FT,FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
Dents are not intended or offered for sale.If,however,the building GAS-EA.SVSTEM-1 ,6}p0
or inipbuilder
wiomum is sold within one year of lie did ion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
Prov er will have the burden of proving that he did not build or im- BU IN
USE
Prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB 0
❑ d as owner of the property,am exclusively .7044,tBu with
licensed ttsions od : re ra the pmcent (Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 8.00 ASSESSORS PARCEL NO.
and Professions Code:The who
Contractor's License s thereon,
Joos not apply
to contracts
owner of property who ba. t r improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
the Contractor's
for such projects with a Convacmr(s)licensed pursuant to
the Qmtractor's License Law. SEWER-SANITARY-STORM EA.20011/1000 ' - ✓L TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec.—,BAP.C.for this
WATER HEATER W/ySNT U0
reason
Owner Date WATER SYSTEM 5.00 _OL ACC.DATE ACC.FILE NO.
WORKERS'COMPENSA'I'ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certilicd
Copy thereof Se 3800,Lab. ). ! rJT! a
Policy No. c ompa 9
O O Cor t m L here y'Tmished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certif o y Is I d will city i pe Pion division.
F OT AI'nheantyy ��� 1 MISC.- REFER TO ORD. / Y ❑ N C] Y ❑ NE]
� T•1 CERTIFICSTF:OP EXEMPTION FROM WOR ERS' PERMIT ISSUANCE y VTC FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE' PLG.CONTE. LIC.NO. PLG
CL C3 ❑ ❑ ❑ ❑
fihis section need nal be completed it line omni it is for one TOTAL Y N Y N
::1 2 hundred dollars IS 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 I- mit is issued,I shall not employ any person in any manner so as to
O W become subject to the Workers'Compcnsmi u,Laws of California.
y Dam Applicant BUILDING 2 NOTICE 'IO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
p, vision, of the Labor Code, you must forthwith comply with FEE
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.NL) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency list EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name 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 c
mlonances n correct. 1 agree ti comply wish all city and county BOILER-COMP13 H.P.or 100,000B,T.U.) 6.00 PLUMBING Q QO
ordinances and state laws relating to building C city an 'O mid
hereby authorim representatives of this airy to ewer upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(Wal
agree,t save, indemnify and keep harmless the City al MISC.- REFER TO ORD.
Cupertino Ag Inst liabilities,judon"Els, Costs and expenses which CONST.TAX
may in an wit ace I against sa'e City in consequence of the PERMIT ISSUANCE 10.00
goofing. hisper L MECH.CONT. LIC.NO. MECR.
/ 1 TOTAL TOTAL
Sgmm a fA pl' o_W_ Date
INSPECTOR COPY