9410 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LOI NG PROJECT I DENT[FI CATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
9410 ADDRESS i F7 t BUILDING-ELECTRICAL-PL BING-MECHANICAL
N PLAN CHECK VALIDATION
NAME CITY• ELECTRIC PERMIT FEE
PHONE
NAMERAcroas UTLETS-SWITCHES-RECEP 10.0011.00
T
p /e LopL_ uc.No. LIGHTING FIXTURES 10.00/1.00
. N Ac OR
PP61ANCES-RESIDENTIAL 4.00
_ ADDRESS
6+ PHONE PANELS pf 10.60 DATE OF APPLICATION
ORclEc PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.No.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH,OR END, PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00
zle EMP.METER OR POLE INS. 20.00
ADDRESS
-MOTORS% SEE FEE S&.
' p
SERVICE CHANGE 20.00 �, p
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 p•%/!-1(�
v b I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business anJ BLDG. ELECT. PLG. MECH.
E. D i Professions Code,and my licens ii,in full force and effect. w ❑ ❑
o0w,w, License Class_ Lic.Number -, El
F Dale Cont LClor
a y f t BUILDING PERMIT
It ¢ ¢ OWNER-BUILDERDECLARATION
¢ w U INFORMATION
R
; LL I I hereby affirm that 1 um exempt from the Contractor's License MISC.- REFER TO ORD
LLoa, Law for the following reason. 7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
�' - Code Any city or county which requiresapermit toccostruct.aher,
¢ m > J p p Y prior to its issuance,also ELEC.CONTR. LIC.NO.
¢ ¢Q improve,Demolish,or repair an structure,p 1 ELEC.
K mLL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
La he is licensed pursuant to the provisions of the Contractor's License
FZQ Law(Chapter 9(commencing with Section 7000)of Division 3 of the ss. -
F 1 O Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT, FEE
¢ G
r m the basis for the alleged exemption.Any violation of Section 7031.5 .. STORIES TYPE CONSTR.
A � � 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(55000.):
❑ 1,as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCG GROUP RES.UNITS
their sole come
pensation,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
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
himselfre throughhe,ownemred for sale
If,cd however,
such ingrrovc
ments ce not intended Or offered for salcvid,d that rich
building GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale). INDUSTRIAL WASTE INTER. 30.00 EE5 IND CON PS Omer
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct lire project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL 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-OV ER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to SEWER-SAN EA.200f[I10.00
the Con Vaci Dr's License Law. TRACT NO, PARCEL NO.
❑ lam'cxenrpt under Sec. ,B.&RC,forthls WATER HEATERAIVVENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACG DATE ACC.FILE N0,
WORKERS'COMPBNSA'I ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby atlirm that I have a certificate o(cunsvd to scll'air,a« ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.)
Policy No. Company 1_,
0 �/ Cl Certifiedcopy is h ereby lar �L FIRE$PRINK ENERGY T-24
OTCarlif^Aopy is fled with he c1lty inspection Ji'.'on. MISC.- REFER TO ORD. ❑ ❑ ❑ ❑
T A bcant_r/-t Y N V N
ir to CERTIFIaAni O'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOOZONEA LU.C.
LU > COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
Z fl'his section need not he completed if the permit is for One TOTAL V❑ N❑ V❑ N❑
hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued, I shall not employ any person in any manner so as to
Ow become subject to the Workers'Compensation Lows of California.
Lu hale Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE TO APPLICANT': If,after making this Ccrtll'icmc of Ex-
(_ 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 UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
tire 9097 Cie C.)� oe of the work for which this permit is issued(Sec MICROFILM
HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 4
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• information is correct. I agree to comply with all city and county PLUMBING
onllii l'oe and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
he¢hy authorize representatives al this city to enter upon the BOILER-COMP(Over 100,000BTUISEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree io Save, indemnity and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which- PERMITISSUANCE 10.00 CONST.TAX
outy in any.way accrue against said City in consequence of tire
granting of this permit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
\ 11:1 1 lJt
64
J/�\ INSPECTOR COPY