9336 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
Sol LDING APPLICATION & PERMIT
ADDRESS
x BUILDING -ELECTRICAL-PLUMBING-MECHANICAL9336
Owo ER'S PLAN CHECK VALIDATION
NAME ` QTY. ELECTRIC PERMIT FEE
��. L' PHONE
EDTRACTOfl'
NAME yT{ Q UTLETS-SWITCHES-RECEP 10.00/1.00
Lm�No. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS t �M PPLIANCES-RESIDENTIAL 4.00
ADDRESS \
1140NE -12-1-' PANELS 10.00 DATE OF APPLICATION
ORARCHITECT' PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
Sac.NO. SIGNS TRANS. 3.00
ADDRRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 lY y/f
s
woo LICENSED CON'FRACfORS DECLARATION TEMP.POLE 30.00
a oSRj I hereby affirm that I in licensed under provisions of Chapter 9 ISSUANCE DATE
yaw (Commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F w z Professions Code,ang my license is in full force and effect ❑ ❑ • ❑
Z,i m License Class _Lia Number
H m R
to Date Contractor
a x M BUILDING PERMIT
¢ ¢ w ¢ OWNER-BUILDER R-BUILDIiR DECLARATION
a a u INFORMATION
w ; u y I hereby author the I am exempt from the Contractor's License MISC.- REFER TO ORD
u o vr Law for the following reason.(Sec.7031.5.Businessand Professions
VALUATION $/FT.
_ PERMIT ISSUANCE 10.00
Code:Any city or county which requirese permit toconstruct,also
¢ 2 Q improve,demolish,or repair any structure,prior m its issuance,also ELEC.CONTR. LIC.NO. ELEC.
- o ¢ requires the applicant for such permit to life a signed statement that TOTAL PERMIT TO
u ta in" he is licensed pursuant to the provisions ol'the Contractor's License
rzQ
Law(Chapter 9(tmemencing with Section 7000)of Division 3 of the
f i c Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE f O"
r[ F o
the basis for the ullCgctl exemption.Any violation of Section 7031.5I STORIES TYPE CONSTR.
n 3 p1 by any applicant for a permit subjects the applicant too civil penalty
of not more than five hundred dollars(S500).): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEV ICE 4.00 OCG GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for Sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,CON D. 5.00
Cade:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 so.FT.FLOOR AREA TOTAL ACREAGE
• himselfre not hrough
ownemployees,forspmvid Cd that such impruvr
mems are nut intended or offered for sale It however,the building GAS-EA.SV STEM-11NC.40UTLETS 6.00
or improventent Is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build Or tin- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER30.00 RES IND CON PB Other
.
❑ I,as owner of the property,am exclusively contracting with -
licensed contractors to construct the project(Sec. 7044,Nosiness LAWN SPRINKLERS-1 INC 5 V.B. •6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law docs oat apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts fur such projects with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200tt/10 00
the Contractor's License Law. �. (r TRACT NO. PARCEL NO.
❑ I am exempt under Ser.-,B.&PC.for lits WATER HEATER W/VENT 6.00
rcuson
Owner Dale WATER SYSTEM 5.00 ACC.DATE ACG FILE NO.
WORK ERS'COMPENSA NON DECLARAI ION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to wittmvne, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
spy I No. (Sec.3800,Lab.C.).
Policy No. Company ryn,E,
❑ CerlilicJcopy is hembyf r�M1cd. � FIRE SPRINK ENERGY T24
Z_ Z ❑ Certified is fled witl lire city inspection division. MISC.- REFER TO ORD.
O' Applicant 6rC-..r✓�y V N V N
Hy� / PERMIT ISSUANCE 1
W FLOOD ZONE A.L.U.C.
CC CF.R'I'IFICATI:OF Ii X['MPI']ON FROM WORKERS' �D
UJ > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL 0 This section need not be completed it'lite permit is for one TOTAL Y E] NE] Y E3 NE]
::) Z hundred dollars(SI00)or less.)'
U O 1 certify that in the performance of If,,work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mil is issued,I shall not employ any person in any manner so as to
O W berme subject tuthe Workers'Compensution Lawsof Call...till.
Q. [)are Applicant ALTER OR ADD TO MECH: 5.00 BUILDING
} m NOTICE '1'0 APPLICAN I': If,after making this CrHil'w,le of E.-
F.. Z 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=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY .-,` AIR HANDLING UNITIOVER 10)000GE.M.) 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.) 18.00
Lender's Name
Lender's Address HEATING UNIT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and state that lire above VENTILATION FAN (SINGLE) 4.00
• information is correct. I agree to comply with all city and county PLUMBING A,,L (/Q
ordinances and State laws relating to building construction, and BOILER-OOMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby autlmria representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL
TWO 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 cunseqpence of the
granlln tIOil permit. MECH.CONT. LIC.NO. MECH.
/�1D04. // �t�/ % 22'FC1 oTgL TOTAL
&gn�f�f'oh ppbcant/ ontract r Dale
INSPECTOR COPY.