9176 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDING PROJECT IDENTIFICATION PERMIT NUMBER
BAODREss O,LD,NG APPLICATION & PERMIT 9176
1 BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
0 PLAN CHECK VALIDATION
NAME� OTY. ELECTRIC PERMIT FEE�
PHONE
.�/ NAMERA To s OUTLETS-SWITCHES-RECEP 10.00/1.00
TLIC.NO. LIGHTING FIXTURES 10.00/1.00
r. Nr ACT 's
ADDRESS PPLIANCES-RESIDENTIAL 4.00
FHONE _ PANELS 10.00 DATE Of APPLICATION
OR PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
Llc.NO. SIGNS TRANS. 3.00
ADDDDRESS ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANAOOR EnT'S MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 G
° ¢ Z TEMP.POLE 30.00 qq c.G/C S
r o o LICENSED CONTRACTORS DECLARATION A /
is U I hereby affirm that I am licensed under provisions of Chapter 9 IS$UAN DATE
Nu (commencing with Section 7000)of Division 3 of the Business and
¢ BLOG. ELECT. PLG. MECH.
H w i Professions Code,and my license is in full Ibrce and effect. ❑ ❑ ❑
o w - License Class Lie.Number
4 w r w Date _Contractor
¢
lea 0",. cd BUILDING PERMIT
w¢ rz w a OWNER-BUILDER D17CLARATION J INFORMATION° n y I hereby affirm that I ore exem t 0'om the Contractors License MISC.- REFER TO ORD
u y P VALUATION
LL O j Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00
W Code:Anycity orcounly which requires a permit to construct,alter,
¢ a Q 2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. EL C.
° m requires the applicant for such permit la file a signed statement that TOTAL PERMIT O
wm he is licensed pursuant to the provisions of the Contractor's License
rZi
Law(Chapter 9(commencing with Section 7000mi'Division3ofthe
- ¢ Business and Professions Code)or that he is exempt therefrom andQTY. PLUMBING PERMIT FEE
¢ r o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONST9.
A. by any applicant lora permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCD.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,AR EA,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 such work FIXTURES-PER TRAP 5.00 SD.FT.FLOOR AREA TOTAL ACREAGE
orents are not
hde ownemployees,fors.providbuscuvsuch improve- GAS-EA.SYSTEM-l 6.00
himself
are nor ugh his
or offered for sola If,ed that s the building
or improvement is sold within one year of completion,the owner- GAS EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or i -m- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON Pa Omer
❑ I,as owner of the properly,am exclusively conrmcting with ❑ ❑ ❑ ❑ ❑ En 7
licensed contractors to 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 docs not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractons)licensed pursuant to SEWER-SANITARY-STORM EA.200tt/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ taco exempt under Sec. ,B.&P.C.I'or this WATER HEATER W/VENT 6.00
^ reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKF RS'COMPF:NSATION DECLARATION WATER TREATING EQUIP. 5.00
/ 1 hereby'affrm that I have a certificate of consent to selpinsure.
or a cCtlifcale of Workers'Compensation In sura ace,or a ectlifed ZONING ENG.SITE NO.
copy thereof
(Sec.3800,Lab.CJ.
Policy No. //na Company �/ �1- - -L-
❑ Ceoited copy is hereby'Irdb:i . J- FIRE SPRINK ENERGY T 24
z Z ❑ Certified copy is ed with the city' inspection division.
.p' Applicanly MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
'dN
CERTIFICATE 01'EXEMPTION('ROM WORKERS' PERMIT.(SSUANCE 10.00 FLOOD ZONE A.L.U.C.
Lu > COAIPENSA'I'ION INSURANCE PLG.CONTR. � LIQ NO. PLG.
Z (This section need not be completed if the permit is for one .:d TOTAL Y❑ N❑ Y❑ No
hundred dollars(5100)or less.)
V O 1 certify that in the performance of the work for which this per-. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in any manner So as to
O become subject to the Workers'Compenszrion Laws of California.
V n Datc Applicant ALTER OR ADD TO MECH. 5.00 'O"ki,�, BUILDING
} m NO'flCli 'f0 AI'I'LIC,IN C'. II',alter making This Certificate of Ex-
r F Z 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
such provisions or this permit shall he deemed revoked AIR HANDLING UNIT(TO 10=421F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
tine erfo mance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name
Lender's Address HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
I cerril'y that I have read this application and stale that rhe above VENTILATION FAN (SINGLE) 4.00 W
• infonnarion is correct, I agree to comply with all city ucti county PLUMBING
ordinances and state laws relating m building construction, and BOILER-COMP(3 H.P.or 100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP Over 100,000 BTU($EE FEE SC H. MECHANICAL Q-0
abovomemioned property for inspection purposes, _
(We) agree to•save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE . 10.00 ;;. CONST.TAX
may in any way accrue against said City in consequence of the
gra 'ng of this permit MECH.CONT. LIC.NO. MECH.
�. �_ . ,� 6-2 C TOTAL 9 Q TOTAL
a are of Applman�i/Conirador Dare(/e 5 0l3
INSPECTOR COPY