9130 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT 1 DENTI FICATION PERMIT NUMBER
0UTDING APPLICATION &PERMIT
ADDRESS t 9130
3 OLLIU - K So /TC D BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME f rile OE1.w L^R•r Q22A CITY. ELECTRIC PERMIT FEE
PHONE
CONTRACT'"'
xOIIo CysivmS OUTLETS-SWITCHES-RECEP 10.00/1.00
X
uc.No. LIGHTING FIXTURES 10.00/1.00
ADDRESS DR's ICOS'7 1//PPEWAL P PPLIANCES-RESIDENTIAL 4.00
V E'zTINO PHONE -7 Q PANELS 10.00 DATE OF APPLICATION
OncNlrEcr PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.c.No.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.
oo Eos ENS. SPECIAL CIRCUIT 5.0Q PERMIT VALIDATION
zip EMP.METER OR POLE INS, 20.00
APPLICANT'$ MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 611 +7 S
<o U I hereby of firm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w ¢ w (commencing with Section 7000)of Division 3 of the Business and BLOC. ELECT. PLG. MECH.
F y z Pro Passions Code,'n I my lieunse is in full Carce'pppp Cfec
o 0 m W License Class Lie.Number `I 11 1 yl ❑lK.
El
H m H Uate 6 r - - Com racf or c -^t
4 y F , BUILDING PERMIT
4 OWNER-BUILDER DECLARATION
E
a D MISC.- REFER TO ORD INFORMATION
w 3 u 1 hereby affirm that 1 am exempt from the Contactor,License VALUATION $/FT.
v- LL 0 4 Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 10.00
Code:Any city or County which requires.permit to construct,alter,
acto ¢ 2O Improve,demolish,Or repair any Structure,prior to Its Issuance',also ELEG CONTR. LIC.NO. ELEC.
ar
0 ¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
A w mhe is licensed pursuant Io the-provisions of the Contractor's License
Fzi
Law(Chapter 9(commencing with Section 7000)ofDivision3ofthe P G
4 Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE /� L
v-o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a ;°' by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
Of not more Ihan five hundred dollars(S5001.)',
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 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
Code:The Contractor's License Law does not apply to an owner of /�/�
property who builds Or improves thereon,and who does Each work FIXTURES-PER TRAP 5= SO.FT,FLOOR AREA TOTALAOREAGE
• himself or through his own employees.provided that such improve- _
meets are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS Rnn
Or improvement is sold within one year of completion, the owner- GAS EASYSTEM OVER 4 IEA.) 2.00
builder will have the burden of proving that h - . -e did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ I,as owner of the property,um cxclusivdy cimracting with ❑ ❑ ❑ ❑ ❑.
licensed contractors In construct the 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 property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts forsuch projects with a contractors)licensed pursuant to
the Contractors License Law. SEWER-S ITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.SP.C.for this WATERH ATER W/VENT 6-W
Ivalon
I Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm Oust I have a enrtilicme of consent IOx96lns[oe' ZONING ENG.SITE NO.
or a certificate of Workers Compensation Insurance,or a certified
copy thereo'ISec. 800,Lab. .1
Policy No y�-��1
O ❑ Certified copy i. r ylurnishe FIRESPRINK ENERGY T 24
z p \❑Ilne��tified cop is II i0 m inspection Division. MISC.- REFER TO ORO. y N Y ry
❑ ❑ ❑ ❑
w� CHkTII'1, Ii OIs EXIiMI'T'ION IB01 URKERS• PERMIT ISSUANCE 'D= �' FL000ZONE A.LU,C.
LU o COMI'ENSATION'INSURA -li PLG.CONTR. LIC.NO. TOTAL 0 1PLGw Y❑ N❑ Y❑ NCL ❑
CL Z (This section need not be completed if the permit is for one
hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAe PERMIT FEE FEE SUMMARY
LL F- alit is issued, I shall not employ any person in any manners..as to
Ow hecome subject to the WorkersCompensation Laws of California. BUILDING
a Date Applicant ALTER OR ADD TO'MECH. 5.00
} to NOTICE.TO APPLICANT: If,after making this Certificate of Ex-
H Z Ent prion,you should become subject is,the Workers Compensation APPLIANCE \_ 5.00 PLAN CHECK
provisions Of the Labor Code, you Trust forthwilh comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT,(TO 10X6CrF.M.) 4.00
CONSTRUCfIONLENDING AGENCY AIR HANDLING UNIT(OVER 10p00GEM.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction binding agency for EXHAUST HOOD'(WITH DUCT) 5.00
the perfornmnce 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
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
1 certify that I have read this application and state thin 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 O
hereby authorise representatives of this city to enter upon the BOILER-COMP(Ovar RX,000 BTU)SEE FEE SCH, MECHANICAL
above-mentioned property unive,pet this
purposes.
(Wa) agree to save, indenmify mid keep harmless the City of MISC.- REFER TO ORD.
Cupertino .gains - I'ties,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any a e against said ty in consequence of the
granting ori per MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signatu[ o' is Contract.. D
INSPECTOR COPY