C9243 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT 1 DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
A0.HESS BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 924.3.
OWNER'S - PLAN CHECK VALIDATION
NAME M� �j L/�r ,�A� .�� QTY. ELECTRIC PERMIT FEE
WI'r E`9 PHONE
NOMERacTORs UTLETS-SWITCHES-RECEP 10.00/1.00 C
LIC,NO. LIGHTING FIXTURES 10.00/11`.00
CONTRACTORS PPLIANCES-RESIDENTIAL :'4.00
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
DR
ENGINEER LJAEe,9,f bIL5EQT PCSSOC.
LIC.NO, SIGNS TRANS. 3.00
ARCH.OR ENG ^ T PERMIT VALIDATION
ADDRESS P 0 M ALA 00
SPECIAL CIRCUIT 5.
Z, EMP.METER OR POLE INS. 20.00
APPuca rs 4!1a MOTORS SEE FEE SCH.
ADDRESS
SERVICECHANGE 20.00 I
ao o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 7
¢ v I hereby affirm that I am licensed under provisions of Chapter 9 IbbUANaE DATE
waw (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F m z Professions Code.and my license is in full force and effect. ElI 1:1 ❑
z o m License Class Lie.Number
9 V- D Date Contractor r
¢ Y s BUILDING PERMIT
¢ a, w ¢ OWNER-BUILDER DECLARATION
o INFORMATION
Oa MISC.- REFER TO ORD
F
3 N 1 hereby affirm that 1 an exempt from the ine,saclnr's License
.. o¢ Law Ibr the following mason.(Sea]031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
r - Code:Any city or county which requires a permit m construct,alter, ,C T
Is Q p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO ELEC. v
- LL rtpikS the applicant fnr such permit to file B signed statement that TOTAL aUU
PERMIT TO
to m he is licensed pursuant to the provisions of the Cmntr.¢tor i License
V, Law(Chapter 9(commencing with Section 7000)of Division 3 of the
io Business and Professions Code)or that he is exempt therefrom and QTY, PLUMBING PERMIT FEE ORT LC
¢ H o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a ;m by any applicant for er permit subjects the applicant toacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(SSOo).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00. Dec.GROUP RES.UNITS
their sole compensation,will do the work,and the st rucuoe is not
intended or offered for sale (See 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 docs such work F IXTUR ES-PER TRAP 5.00 SD.FT,FLOOR AREA TOTAL ACREAGE
himself re Through his own employees.Safe.
If,provided that such improve-
ments mselfo not intended or employees.ffered for lelLed that such[lie building GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement Is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did Amt huild or im
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Othe,
C1 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct 11m 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 properly who builds or improves thereon.and who LAWN SPR IN KLERS-OVER 5(EA.) 1.00
Contracts for such projects with a contractor(s)licensed pursuant to SEWER-SANITAR V-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ l am exempt under Sec. � ,BAP.C.for this WATER HEATER W/VENT 6.00
tro"
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
IS
WORKER COh1PliNsnno� oN.. WATER TREATING EQUIP, 5.00
col hereby of firm that I.have a certificate of consent to self-insure.
or a certificntc Of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec,3800,Lab CA '
Policy No. Company
O ❑ Certified copy is hereby furnished.
^z . El Certified copy is'Illed with the city inspection division. FIRE SPRINK ENERGY L24
2
MISC.- REFER TO ORD.
O', Applicant Y❑ N❑ Y ❑ N❑
~ rn PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
CCCIiRTIFICATf$OF IiXIiMPTION FROMWORKIiRS'
LU D COMP)NSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
Q.Q. 0 ('1'[,1, section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N El
hundred dollars(S 100)or less.)
U 0 1 certify that In the performance of the work to,which thts per QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued.I shall not employ any person in any"runner so as to
O W become subject to the Workers'Compensation Laws of California.
CL D'°m nppl'°a"t. ALTER OR ADD TO MECH. 5.00 BUILDING U(i
} to .NOTICE '10 APPLICANT.. If,after making this Certificate of Ex-
F_ Z_ empficn,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 dc,med revoked. AIR HANDLING UNIT(TO 10,000CF.M.) 4.00
CONSTRucT15�K DING AGENCY / AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE S7/
1 herchy Want that there is. construction lending agency for I EXHAUST HOOD(WITH DUCT) 5.00
-' the performance of Ibe work for which this permit is issued(Sec. MICROFILM
3097,Civ-C.) 1' r HEATING UNIT(TO 100,000 B.T.U.1 8.00 x
Lenders Name
Lender's Address r. HEATING UNIT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
I certify that l haveread'thisapplicTiot and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to Comply with all city and county PLUMBING
"dimness and stat, laws relating Ise building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby autlmoee representatives of this City to enter/upon the BOILER-COMP Over imooO BTU)SEE FEE SCH. MECHANICAL
above mentioned property for inspection purposes. I
(We) agree to save, indemnify andtkeep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and eapenscs which CONST.TAX
may in any way accrue against Said City in consequence of the PERMIT ISSUANCE 10.00
gran tin f this permit. MECH.CONT. LIG NO. MECH.
` TOTAL TOTAL
SighatIES of App t m c ate
X INSPECTOR COPY
1
"IRR I