9456 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI F[CATION PERMIT NUMBER
EDOREED IN APPLICATION & PERMIT 9456
ss
BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
OWNERS - PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
• •S PHONE
NAME�CF°ROUTLETS-SWITCHES-RECEP 10.00/1.00
fi d,,f 40C.NO, LIGHTING FIXTURES 10.00/1.00
DDRESS DR's
ADDRESS PPLIANCES-RESIDENTIAL 4.00
PHONE 70-7 PANELS 10.00 DATE OF APPLICATION
A CHI C PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.No. SIGNS TRANS. 3.00 ,q
ADDRESS ENG SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
ADDRESS rs MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
° ¢ TEMP.POLE 30.00
r O o LICENSED CONTRACTORS DECLARATION
a it U 'I hereby arrant that I ran licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and
BLDG. ELECT. PLG. MECH.
.2 Professions Code,and my license is in full force and effect. ❑ ❑ ❑ ❑
z 0 - License Class Lie Number yr' 3
S? h H j Date- IQj Contractor
a y E � 1 BUILDING PERMIT
to w a OWNER-BUILDER DECLARATION
A O A u INFORMATION
w3 N I hereby affuru that I am exempt from Om Contractor's License MISC.- REFER TO ORD
u O a Law for the following reason.(Sec.7031.5,Businessand Professions VALUATION S/FT.
_ PERMIT ISSUANCE 10.00
Code:Any city or county which mquiresa permit to Construct,alter, 3 �Q
ac p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. /
A ° LL requires the applicant I'nr such permit to file a signed statement that TOTAL - PERMIT TO
w m he is licensed pursuant to the provisions at tire Contractor's License �s ^
F i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe Y
E i c Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE / C Ai 7i'f•CpO
H$ the basis for the alleged exemption.Any violation of$eclion 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant toa civil penalty
of not more than five hundred dollars($5000.). ALTER-DRAIN& VENT-WATER (EA.) 5.00 p•.+✓•
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 Oce.caouP RES.UNITS
sole compensation,will do the work.and the structure is not
intended or offered for sale (Sea 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contract(,,',License Law docs not apply to an owner of
properly"who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SD.FT.FLOOR AREA TOTAL ACREAGE
himself Randy re through his own employees,provided that such iml?rove-
orimprovementissolnet doroffeoneyeaale.If,however,the thebuilding GAS-EA_SYSTEM-11NC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 (EA) 200
builder will Ilene the burden of proving - . - . .
Ing that he did not build or on- BUILDING USE
prove fors owner of sated. INDUSTRIAL WASTE INTER. 30.00 RES Irvo cory ve Omer
❑ d as owner rs the properly,he exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors : Construct the priced(Sec 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License s th docs not apply
to airownerfor
o1'property who builds or improves thereon,and who LAWN SPR IN KLERS-OVER 5 (EA.) 1.00
contracts for such eL,with n Wntrndorf s]licensed pursuant hI .'e.
Orn Contractor's Li"ccnsnsu Luw. SEWER-SANITARY-$TORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,B&T.C.for this WATER HEATER W/VENT 6.00
,Calvin
Owner - Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate are onscar to self-insure. ZONING
Or a Certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
Copy therco((Sec.3800,Lab.C.).
,Policy No. Company
O ❑ Certified Copy is hereby furnished. WNQ$]fIOJLF FIRE SPRINK ENERGY T-24
Z Z ❑ Certified op is 1i•d ;Zdh, city spec+on drvisiun.
Z Appbcant ,g,t- � MISC.- REFER TO ORD, v ❑ m❑ v ❑ No
~ �+ PERMIT ISSUANCE 10.00
Q: - CERTIFICATE OF EXEMPTION I'R(Jh1 WORKERS' FLOOD ZONE A.L.U.C.
LU - COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
CL Z
(This section need not be completed if tire C:] N❑
e permit is for one TOTAL V❑ N❑ Y
hundred dollars IS 100)or Ie111
U O I certify that in the performance of me work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- (nit is issued,I shall not employ any person in any manner so as to
O L) become subject to the Workers'Compton,i ion Laws of Califoraiu
C. Dad APPhcant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of Fix
F" Z Joc
eruption,you should become subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK
provisions of Ore labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.NL) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNITIOVER 10,000GEM.) 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.CJ, HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that l have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree m comply with all city and county PLUMBING
ordinances and slate laws relating to building construction, and 130ILER-COMP(3H.P.or10O,0008.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property I'or inspection purposes. BOILER-COMP (Over 100,000 BTU(SEE FEE SCH. MECHANICAL
(WO agree to Neve, 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
miry in any way accnm against said City in consequence of the
"anti tltis Pcnni4-0
L MECH.CONT. LIC.NO. MECH.
OTAL TOTAL 9
ie at re A Ilea I/ on c r Dale
INSPECTOR COPY