9359 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECTlDENTIFICATION APPLICATION & PERMIT PERMIT NUMBER
t_ BN"°'"° 9359
T AOnRESS
t� 72 .STL✓<=R//IOJ /�✓(-� BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
"AME ••�a,( QTY. ELECTRIC PERMIT FEE
•
CONTRACTORS
/1y Ci*�Y ONE�jI O OJ
NAME CTORs OUTLETS-SWITCHES-RECEP 10.00/1.00 /
NAME
`o xw1.F N ( p T. LIC,NOLIGHTING FIXTURES 10.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
ADDRESS
7 A/ 3 J"pr�/ , J,7 PHONE /' � ��p tf'l PANELS 10.00 DATE OF APPLICATION
ARCHITECT { PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER I.
LIC.No. SIGNS TRANS. 3.00
ADDRESS END, PERMIT CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEJ.METER OR POLE INS. 20.00
ADDRESS r$ MOT RS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
0 0 0 - LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 ��V/Q p
a u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
H a w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F m z Professions Cod a d my license is in full force and effect. ❑ ❑ ❑ ❑
z o v`-0-- License Class c�� Lie.Number t(� �e 2
o r Uatc Contmen-4-,��y�.a_�`_�r
st Y s BUILDING PERMIT
¢ ¢ w o OWNER-BUILDER DECLARATION INFORMATION
w ;, I- I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION SIFT.
Fa- 0 Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE
Code:Any city or county which requires a permit to Construct,alter,
a ¢a improve,demolish,or repair any structure,prior m its issuance,also ELEC.CONTE. LIC.NO. ELEC.
va
0¢ requires the applicant for such permit to file a signed statement that TOTAL d PERMIT TO
i
n w m U- he is licensed pursuant to the provisions of the Contractor's License
Law(Chapter 9(commencing with Section 7000)offlivision 3 ofthe �
r a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE C/ i 0 Le-
f x o
OF I o the basis for the alleged exemption.Any violation u(Section 7031.$ 1 STORIES - TYPE CONSTR.
dam _ by any applicant far a pemnitsubjecls the applicant to a Civil penalty ALTER-DRAIN&VENT-WATER IEA.) 5.00
of not more than five hundred dollars(S500.):
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00 OCC.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,AREA,COND. 5.00
Coda: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
, •
himself or throu
ghde own r olureoyees, leoIi.hJ ever,hat the
impnun- GAS-EA.SYSTEM-1 6.00
mems ro not intended or offered for sale.IL however,the bmWing
or improvement art is e b 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 tinct not build
or am- RES IND CON PB Other
prove for purpose.1 Sale.), INDUSTRIAL WASTE INTER. 30.00
❑ d as owner of the property,am ex jest(ty contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec 7044,of apply LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Codec The Contractor'sbuildsLicense Law docs not who
to ft owner of property who,builds t r improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00'
the facts fill L cenW L with u contmctrx(s)license(]pursuant m SEWER-SANITARY-STORM EA.200ft/10.00
the Con acetols License Law. TRACT NO. PARCEL NO.
❑ lam exempt under See-,B.NtP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK FRS'COMPENSAT'ION DECLAKAT'ION WATER TREATING EQUIP. 5.00
1 herchy affirm that I hove a cvrtilicutc of consent to sell-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Come Compensation Insurance,or a ecTtifiml
copyflercoft!oc.3800,Lnb.CA
Policy No. Company JAim.A14"1'4 U11
❑ Certified copy is hereby famished. _ FIRESPRINK ENERGYT-24
Z Z ❑ Certified th
ropy is fled wits e city inspection division. MISC.
O Applicant - REFER TO ORD.
r Is rAY-- { St Y ❑ N❑. Y ❑ N❑
fr T CERTIFICATE 01'EXEMPT 10N FROM WORKERS' - PERMIT ISSUANCE 10.00 FLOODZONE / A.L.U.C.
LU > COhIPENSATION INSURANCE PLG.CONTE. LIC.No. PLG.
CL 0 ('('his section need not be completed if IIIc permit is for One TOTAL Y❑ N❑ V ❑ N❑
hundred dollars IS 100)or less.)
U O 1 certify that in Ire Performance of the work for which this Per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued, 1 shell not a Ploy any person in any manner so as to
O become subject to the Workers'Compensation Laws of California.
a Dato Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} w NOTICE, TO APPLICANT': If,after making this Certificate of Ex-
F 2 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' \
V 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.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is A construction landing agency for EXHAUST HOOD (WITH DUCT) 5.00
the 3097 performance MICROFILM
Civ.C.) of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address H EATI NG UNIT(OVER 100,000 B.T.U.)9.50 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
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 BOILER-COMP (over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned proper y inspection purpous.
(We) agree to s fe i emnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against to s,hull, ants, costs and expenses which - CONST.TAX
may in any w a e agai said City in consequence of the PERMIT ISSUANCE 10.00
granting oft a MECH.CONT. LIC.NO. MFCH.
` 67 TOTAL TOTAL
'^-� Signal o Applicans ont clnr ale
INSPECTOR COPY