Loading...
C9250APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT I DENTIFICATJdkWAPPLICATION & PEF* BUILDING - ELECTRICAL- PLUMBING -'MECHANICAL PERMIT NUMBER 9250 ING A D DR Ess AQOR Ess A u S NAME "y]/ "'I/ /t /A.d/1RDNE R' A/W��GG ii /S VrJ P QTY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION /({ " 13, i, CONTRA ORs AME UTLETS-SWITCHES-RECEP-.10.00/1.00 ,N� LIGHTING FIXTURES 10.00/1.00L CONTRACTORS " ADDRESS y/s �r� APPLIANCES- RESIDENTIAL 4.00 PANELS 10,020 //.,, .//7 ,TS��S" PRONE3 27 QO DATE OF APPLICATION ARCHITECTOR PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE BC. NO. ENGINEER s. uc. No. � SIGNS TRANS. 3.00 AARCH, OR DDRESS ENG. SPECIALCIRCUIT 5.00 PERMIT VALIDATION TEMP. METER OR POLE INS. 20.00 ZIP C 1 f; /O AoREss� ADDRESS MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 LICENSED CONTRACTORS DECLARATION TEMP. POLE 30.00 1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Cod nd my se is in full force . delle t. License Cl, // ����,� Lic. Number ' Date+'�'"t'-TContractor ISSUANCE DATE BLDG. I ELECT.1 PLG. MECH. 7 C OWNER -BUILDER DECLARATION I Hereby affirm that 1 am exempt from the Contractor's License Law for the following reason(Sec.uires permit to Professions Cade: e, dem y sh countypair any reqstructure, x p prior require¢, demolish. Or repair any structure, prior m its issuance, also to consuan e, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions o(the Contractor's License BUILDING PERMIT INFORMATION MISC.- REFER TO ORD PERMIT ISSUANCE s /10. VALUATION $/FT, ELEC. CONTR. LIC. NO. TOTAL PERMIT TO QTY. PLUMBING PERMIT FEE of Division 3 of the Law (Chapter 9 (commencing with Section is exempt and Business and Professions Code) or that he lobo of ectio 70 for the alleged exemption. Any violation of Section ST RI vP CONSTR. by any permit subjects the 0R.): am loacivil penalty malty by any more for five of not maze than five dollars (55001.): ALTER -DRAIN MA.) 5.00 ❑ L az owner et the property, or my employees with wages as he prop their sole compensation, will Jo lire work, and the structure rs not BACK F LOW PROTECT. DEV ICE 4.00 OCC. GRO P 5. UNITS DRAINS -FLOOR, ROOF, AR EA, COND. 5.00 i ,intended or offered for sale (Sec. 7044. Business and Professions Code: The Contractor's License Law does not apply to an owner of FIXTURES - PER TRAP 5.00 SO, FT FLOOR AREA TOTAL ACREAGE property who builds or improves thereon, and who does such work himself or through his own employees, provided that such improve- ments are not intended or offered for sale. If, however, the building GAS - EA. SYSTEM -1INC. 4 OUTLETS 6.00 or improvement is sold within one year of completion, the owner- builder will have the burden of proving that he did not build or im- prove 1, as ownerose of the p ❑ I, as owner of the property. am exclusively contracting with GAS - EA. SYSTEM -OVER 4 (EA.) 2.00 BUILDING USE RE IND CON PB Other ❑ ❑ ❑ ❑ INDUSTRIAL WASTE INTER. 30.00 LAWN SPRINKLERS - 1 INC 5 V.B. 6.00 LAWN SPRINKLERS- OVER 5 (EA.1 1.00 licensed contractors to construct the project (See 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who ASSESSORS PARCEL NO. contracts for such projects with a contractors) licensed pursuant to lire Contractors License Law. SEWER -SANITARY -STORM EA. 200ft/10.00 TRACT NO. PARCEL NO. ❑ I dm exempt under Sec. ,B.&P.C. Drift' reason WATER HEATER W/VENT 6.00 Owner Uate WATER SYSTEM 5.00 ACC.OATE ACC. FILE NO. WATER TREATING EQUIP. 5.00 WORKERS'COMP(:NSATION DECLARATION I hereby affirm that 1 have a certificate ofconseat 10 self-insuce. or u'econficate of Workers' Compensation Insurance, or .-certified' ZONING ENG. SITE N0. copy thereof (Sec. 3800, Lab.C.). Policy No. Company ['� FIRE SPRINK Y ❑ N❑ FLOOD ZONE ENERGY T 24 Y ❑ N❑ A.L.U.C. ❑ Certified copy' is h by furnished r❑'Cxertified op s -f with to divisio P1 %r _ I MISC. - REFER TO PRO. �( CE IC(A L OF L\LM PT ION FRONI WORKERS' PERMIT ISSUANCE 10.00 PLG. CONTR. LIC. NO. PLG. TOTAL az �/ COMPENSATION INSURANCE (This section need not be completed if the permit is for one Y ❑ N ❑ Y ❑ N ❑ hundred dollars IS 100) or Iess.) I certify that in the performance of the work for which this per- mit is issued, I shall not employ any person in any manner so as to QTY. MECHANICAL PERMIT FEE FEE SUMMARY BUILDING become subject to the Workers' Compensation Laws of California. Date Applicant ALTER OR ADD TO MECH. 5.00 NOTICE TO APPLICANT: If, alter making this Certificate of P:x- APPLIANCE 5.00 PLAN CHECK emption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked AIR HANDLING UNIT (TO 10=C.F.M.) 4.00 FEE ' AIR HANDLING UNIT(OVER I0,000C.F.M.) 6.00 SEISMIC FEE CONSTRUCTION LENDING AGENCY 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. 3097. Civ.C.l. MICROFILM HEATING UNIT (T0 100,000 B.T.U.) 8.00 Lender's Name Lender's Address HEATING UNIT (OVER 100,000 B.T.U.)9.50 ELECTRIC I certify that l 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 ordinances and state laws relating to 18uiliing construction, and PLUMBING BOILER -COMP 13 H.P. or 100,000 B.T.U.) 6. 0 g0 ER -COMP (Over 100,000 BTU($EE FEE SCH. MECHANICAL hereby authorize representatives of (his city 10 enter upon the above-mentioned properly for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may in any way accrue against id Pity in consequence of the MISC. - REFER TO ORD. CONST. TAX PERMIT ISSUANCE 10.00 granting of lhjs LL. r MECH. CONT. LIC. NO. MECH, TOTALOD TOTAL I i �Pl Signa o I M ontracto Date --� INSPECTOR COPY /'