9234 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADORESs
/ BUILDING - ELECTRICAL-PLUMBING -MECHANICAa 0Q1?
09 L 9234
:CAPER 5 PLAN CHECK VALIDATION
NAME ' QTY. ELECTRIC PERMIT FEE
orvE
�5ZNAM " R
R
EUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO, LIGHTING FIXTURES 10.00/1.00
Ums PPLIANCES-RESIDENTIAL 4.00
ACONETRAREss
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH,OR ENG' SPECIAL CIRCUIT S.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 /1
ADDRESS ESS MOTORS SEE FEE SCH. �.p'
ADDRESS
SERVICE CHANGE ZQ,00 0-.
0 o O LICENSED CONTRACTORS DECLARATION TEMP. POLE 30.00
att w I hereby uffirn that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
w
(commencing with Section 7000)of Division 3 of the Business and¢ mBLDG. ELECT. PLG. MECH.
H y 2 Professions Code,and my license is in full force and effect. ❑ ® ❑ ❑
oi w C License Class Lie Number
F g r J
Date Contractor
a m M of -"'�� BUILDING PERMIT
¢ ¢ ¢ OWNIiR-OUILDT;R DECLARATION
o P. u INFORMATION
X
; LL I hereby oflinn the I ren exempt I'mm the Contractor's License MISC.- REFER TO ORD
G VALUATION $/FT.
H1. oj Law for ly,ity ni-ingreason.ch regircruicrant tocnd Profess ions PERMIT ISSUANCE v 10.0(1 Pc
Code:Any city nr county which requirese permit to construct, also C-
Qre 4 p improve,dl-InOIRh,U!repair any SlrnetnR,prior IU IIS ISSllanel',llISU ELEC.CONTR. LIC.NO. ELEC.
DLL requires the applicant For such permit to file a Signed statement that )y TOTAL PERMIT TO
w m es he is licensed pursuant to the provisions of the Contractor's License
H. > Law(Chapter 9(commencing with Section 7000)of Division 3 of the -
io Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE L2 V( L Cz -C-K
IS $ the basis for the alleged exemption.Any violation of8eetion 7031.5 STORIES TYPE CONSTR.
a � by any apPlicunt for a permit subjects lire applicant to a civil penally ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(55001.):
❑ I,as owner of fire property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
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
properly who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
mems are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS EASYSTEM OVER 4(EA.) 2.00
builder will have tile burden of proving that he did not build or ire- - . -
BUILDING USE
prove for purpose of sale). RES IND CON PB Other
❑ 1,as owner of the property,am exclusively contracting with ❑ 0 ❑ ❑ ❑
licensed coinrachmS 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 does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for Such projectSw'ith a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ I am exempt under See,-,B.&P.C.for this WATER HEATER W/VENT 6.00
easnn
(ywncr, Date WATER SYSTEM 5.00
/((�,/� ACC.DATE ACC.FILE NO.
OR KERS'COMPIiN'SATION DECLARATION / WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofconsent to self-insure, ZONING ENG.SITE NO.
or a certif c.de of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.f
Policy No. Company
O ❑ Certified copy lS hereby famished. FIRE SPRINK ENERGY T.24
Z Z ❑ Certified copy is filed with the city inspection division. MISC- REFER TO ORD.
Q Applicant
I- Y ❑ IN Y [] NE]
va
CC - CERT'][;]CAI[:01;EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00� FLODD ZONE A.L.U.C.
LLI > COMPENSATION INSURANCE ( PLG.CONTR. LIC.NO. PLG.
CL Z (This section need not be completed if the permit is for One TOTAL Y[] N[JY C] NEI
hundred dollars(S 100)or less-)
U 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 shun not employ any person in any manner so as to
Ow become subject to the Workers'Compensation Laws of California.
ED Date - Applicant BUILDING
>_ to NOR . 'TO APPI-(CANT: If,after nl akin;this Certificate of fix- ALTER OR ADD TO MECH. 5.00
e" ? mnption,you should beconw subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of lire Labor Code, you most I'orlhwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.N7) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE
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. MICROFILM
3097,Civ.0.). - 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 C/v
IcerLEY thuslfree,read this application and slate 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 property for Inspection purposes.
(We) agree m save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
4may in any ay accrue against said City in consequence of the PERMIT ISSUANCE 10.00
gm Lg of hie Limit. MECH.CONT. LIC.NO. MECH. .
-711TOTAL TOTAL
u e an/Conti ctor Date
INSPECTOR COPY