9347 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING ^ APPLICATION & PERMIT
AD DR Ess �d
�! BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 9347
E .S PLAN CHECK VALIDATION
NAME ` QTY. ELECTRIC PERMIT FEE
IC11 PHONE
•' CONTRACTORS j1TLETS-SWITCHES-RECEP 10.00/1.00
NAME
BLDODFW0A10 &erTRI( LIC.NO, k41519 74J LIGHTING FIXTURES 10.00/1.00
CON HRAOrORs pPLIANCES-RESIDENTIAL 4.00
AOORESS p/ t( q
231 51 HAOARTSON PHONE ZDV pb10 PANELS 10.00 DATE OF APPLICATION
ORRCHIiECi PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH,OR END' SPECIAL CIRCUIT 5.00 PERMIT VALIDATIONADDRESS '
-44
ZIP TEMP.METER OR POLE INS. 20.00 PAID ppEE ,
APPLE DDRCANT r$
ADDRESS MOTORS SEE FEE SCH. JUL !� 3 19VJ
SERVICE CHANGE 20.00
maio LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
Cityof Noertino
a u w I hereby u(fuit that Sec I am licensed under provisions of Chapter 9 ISSUA CE DATE
m (commencing with Section 70001 of Division 3 of the Business and
a y BLDG. ELEC PLG. MECH.
D Z Professions Code,and my license is in full force and effect.
0 m ❑ E1 11z o - License Class G I D m
,Lin.No 4/it 9 T
g o t Um< l 3r- Bj Contractort
a x I BU DING PERMIT
rc a u OWNER-BUILDER DECLARATION FORMATION
wg u I I hereby affirm that 1 ant exempt from the Contractor's License MISC.- REFER TO ORD
uoa Law forthe following reason.(See.7031.5,Btrsinessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
r Code:Any city or county which reyuiresa permit m emmItrucLalle'.
R -so Q FO improve,demolish, or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
- Ii requires the applicant for such permit to file a signed stalentenl that TOTAL Ile
R
m u, he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
Fi >
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
a Business and Professions Code)or that he is exempt therefrom and QTY
. PLUMBING PERMIT FEE
¢ e the basis for the alleged exemption.Any violation o(Seetion 703 LS -STORres TYPE CONSTR.
;m by any applicant for d permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollms($500).):
Cl 1,as owner of the property,or my anpluycea with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole copensation,will do the work,and the Ft mcture is not OCC.GROUP RES.UNITS
m
intended or offered for sale (Sce. 7044, lousiness and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:'the Contractors License Law does not apply W rut owner of
property who builds or Iinproves thereon,and who does such work FIXTURES-PER TRAP 5.00 $0.FT,FLOOR AREA TOTALACREAGE
meats are not
hde ownemied torsale,If,ed however,(lie
intprovg GAS-EA.SYSTEM-11NC.40UTLETS 6.00 a,_s r'
meets are not it is sold ar oRm ed for sale.If,however,the building
or oder will av is cold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prover will phave urpose
f burden of proving that he did not build or'nm
prove fors ownsc of sale.). INDUSTRIAL WASTE INTER. 30.00 R IND CON. PB omar
❑ d as namom(the property,he exclusively. 7044,contracting with
licensed contractors to construct the Project IScc. 7044, Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and n owner bs'Cod e The Contractor's's reproves
Law docs ort apply
to tr owner of property who builds t r improves thereon,and who LAWN SPRINKLE RS-OVER 5 (EA.) 1.00
contracts ctor'sor hcenseuwitbucontruetor(sl licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License low. TRACT NO. PARCEL NO.
❑ Inm exempt under Sec. ,H.&It C.Citr this WATER HEATER W/VENT 6.00
reason
Owner Dare WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO.
WORK ERS'C'OM PP.NSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure ZONING ZONING ENSITE NO.
br a certificate of Workers Compensation Insurance,ar a certified
- / copy thereof(Scc.3800,Lab.C.).
X Policy No. Company
Q ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z z ❑ Certified copy is Cited with the city inspection division. MISC.- REFER TO ORD.
Applicant Y [] N[] Y D N�
~ y PERMIT ISSUANCE 10.00
Ir - CERT(PICATIi H l A\ IO TION FROM WORKERS' FLOOD ZONE A.L.U.C.
W COd art be coo INSURANCE the PLG.CONTR. LIC.NO, PLG. Y E] N� v 0 N E]
Z (This section need not be completed i(the permit is for one TOTAL
hundred dollars I S 1001 pe less.)
U O I certify that h l n performance of the work for which this per. CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I shall not employ any person in any manner so as to
M1emmc subject m the Workers'Compensation Laws of California
0 y nate-1'--2sf�Btinpvlicam - ALTER OR ADD TO MECH. 5.00 BUILDING
} w IN ICI O 'N CAN If,ati m k g h CcrUIuE IC of f
F. Z emption,you should become subjen t the Workers'Cmnpensatiun APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE 1
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 10MC.P.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the Herr..mance of the work for which this permit is issued(Sec MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)Lender's Address ELECTRIC
1 certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 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 authorize representatives of this city to enter upon the
above-mentioned properly for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgmmnpdcosts and expenses which PERMITISSUANCE 10.00 CONST.TAX
stay in any way accrue against saidichy in consequence of the
granting of this permit y` MECH.CONT. LIC.N0. MECH.
1 k 2Y_ orAL TOTAL
tar of Apptcent/ ntractor 'y Uutc
INSPECTOR COPY
I