9505APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
9505
BUILDING
ADORESs
0 NAME S CN��t j y a A N
NAME L 'L-rr
QTV.
-
ELECTRIC PERMIT
FEE
PLAN CHECK VALIDATION
ONE I
t
CONTRACTORS
UTLETS - SWITCHES - RECEP 10.00/1.00
T /U IC NO
DATE OF APPLICATION
LIGHTING FIXTURES 10.00/1.00
noo�ses --s��••s roRS
�p I/ICT PRONE-
PPLIANCES - RESIDENTIAL 4.00
PANELS 10.00
ORRCRITECT
ENGINEER
' Sec. NO.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P. C. NO.
SIGNS TRANS. 3.00
ADDRESS ENa
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
FrEMP. METER OR POLE INS. 20.00
ZIP
ADDRESS is
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
D
LICENSED CONTRACTORS DECLARATION
TEMP. POLE 30.00
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license �{ is in full force and effect.
License Class C. Number
ISSUANCE DATE
BLDG. ELECT. PLO.- MECH.
❑ O ❑ ❑
Tl
Uate Conlmctor
OWNER - BUILDER DECLARATION
I hereby aoll. that I um exempt from the inc,antors License
Law for the followingreason .(Sec.70315.ermit tocndtruct,salons
Code; Any counpair any structurep Prior
improve, demolish. appicant for such h y structure, pa signs is issuance. also
he is tic the applicant for inch permit to file a signed actor's i that
he is licensed pursuant to the provisions of the )ont 's License
(Chapter Section 7000)on-Division ofthe
BUILDING PERMIT
INFORMATION
MISC.- REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
8,O�s C/4
r�u
S /FT.
ELEC. CONTR. LIC. NO.
ELEC.
TOTAL
PERMIT TO
+�
Business and
Badness umd Professions ns Codel or that he is exempt therefrom and
Code) or hrirom and
QTY.
PLUMBING PERMIT
FEE
✓
by of applicant fora permit subjects the applicant toacivil penalty
by basis for Ian for aJ exemption. Any violation t toacliun malty
of not more than five hundred dollars (myem):
STORIES
TYPE
TYPE CONSTR.
ALTER- DRAIN &VENT-WATER (EA.) 5.00
O Las owner at the will do t e my employees with wages as
(heir sole compensation, will do the work, and line structure is not
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS - FLOOR, ROOF, AREA, COND. 5.00
intended or offered for sale (Sec. 7044, Business and I'mfesslons
Cod, 'fine Contractors License Law does not apply to an owner of
FIXTURES - PER TRAP 5.00
GAS- EA- SYSTEM 6.00
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
So. FT. FLOOR AREA
TOTALACREAGE
or improvement is sold within one year of completion, Ilia owner-
builder will have the burden of proving that he did not build or im-
GAS - EA. SYSTEM -OVER 4 (EA.) 2.00
BUILDING USE
prove for purpose of sale.).
❑ I, as owner of the property, am exclusively contracting with
RES IND CON PB Omer
C1 El Q, El 11
INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct ilia project (Sec. 7044, Nosiness
and Professions Code: The Contractor's License Law does not apply
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
ASSESSORS PARCEL NO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
to an owner of properly who builds or improves thereon. and who
contracts for such projects with a contractorfs) licensed pursuant to
the Contractors License Law.
❑ I;un exempt under Sec ,B. &I'.C. for mix
on
SEWER-SANITARY-STORM V -STORM EA. 200ft /10.00
TRACT NO.
PARCELNO.
WATER HEATER W /VENT 6.00
Owner Date
WATER SYSTEM - 5.00
ACC. DATE
ACC. FILE NO,
WORT: ERS'CONIPENSATION DECLARATION
WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self- insure,
ZONING
ENG. SITE NO.
or a certificate of Workers' Compensmion Insurance, or a certified
,copy them.1 (Sce. 3800, Lab.C.).
Policy No. Company
O Certified copy is hereby furnished.
❑ city inspection division.
Applicant �F1,f�{� -,
`
FIRE SPRINK
Y E] N E]
ENERGY T 24
Y C] N[:]
MISC. - REFER TO ORD.
rLry,
C17RT1171CATI: 01: [:XEMP7'ION PROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.U.C.
COh1PENSATION INSURANCE:
(This Section Reed not be completed if the permit is for one
PLO. CONTR. LIC. NO.
P LG
TOTAL s
Y ❑ NE:]
Y ❑ N
hundred dollars IS 100) or less.)
I terrify that in me performance of the work for which this per-
mR is issued, I'shall not employ any person in any manner so as to
QTV
MECHANICAL PERMIT
FEE
FEE SUMMARY
BUILDING
/ v
1
become subject to the Workers' Compensation Laws of California.
Date Applicant
ALTER OR ADD TO MECH. 5.00
NOTICE '1'O APPLICANT': II, after making Ibis Cert ificata of Ex-
APPLIANCE 5.00
AIR HANDLING UNIT (TO 10=C.F.NL) 4.00
PLAN CHECK
FEE
emption, you should become subject to the Workers' Compensation
provisions of ilia Labor Code, you must forthwith comply with
such provisions or this permit shall be deened revoked.
AIR HANDLING UNITIOVER 10,000C.F.M.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that Thera 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. CN.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address
HEATING UN IT (OVER 100,000 B.T.U.) 9.50
ELECTRIC
VENTILATION FAN (SINGLE) 4.00
I certify that I have read this application and slate That 11e above
information is correct, 1 agree to comply with all city and county
oNfnan acs and smte laws relating to building constn;etion, and
PLUMBING
BOILER- COMP13 H.P. or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above - mentioned property 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 ORE.
Cupertino against liabilities, judgments, costs and expenses which
may in any way Sear.. agamsl said City in consequence of the
grant i g f this par mj!(
PERMIT ISSUANCE 10.00
CONST. TAX
MECH. CONT. LOC. NO.
MECH.
TOTAL
TOTAL
a y4 �l
igh2drEblApVtontit-orumbor ate
INSPECTOR COPY