C9425 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN.ONLY
PERMIT NUMBER
BUILDING PROJECT APPLICATION & PERMIT
BUILDING 9425
ADDRESS r BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
N
OWNER'S PLAN CHECK VALIDATION
NAME /` QTY. ELECTRIC PERMIT FEE
CONTRACTORS
NAME
ONTACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
Lie.No. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR S PPLIANCES-RESIDENTIAL 4.00
AGRA ESS
PHONE PANELS 10.00 DATE OF APPLICATION
OR
RcwTECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
/
ENGINEER
uc.No. SIGNS TRANS. 3.00
ARCH.OR ADDRESS ENG. SPECIAL CIRCUIT' 5.0D 'PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 n
APPLICANTS a MOTORS SEE FEF4SCH. pn l.*/'C�ie`J
ADDRESS �? f 30 /L( .1/ 04: f.' h /e
(. < i-, - �•A C/7r;.( V SERVICE CHANGE 20.00 ItsG
° a z ! TEMP. POLE 30.00
0 o y/O
F LICEN'SED CONTRACTORS DECLARATION
< L," 'u I hereby afl'ion that I am licensed under provisions of Chapter 9 ISSUANCE DATE
� (amsmeneing with Section 7000)of Division 3 of the Business and n Q A BLDG I ELECT. PLG. MECH.
F n i Professions Code,and my license is in full force and effect. - ❑ ❑ ❑
o
0 m o License Class Lic.Number
Dote Contractor
Y d BUILDING PERMIT
w Ly OWNIi R-BUILDF,R DECLARATION INFORMATION
X 3 LL w I hereby aflinn that 1 am exempt from the Contractor's License MISC.- REFER TO;ORD
Fu04 Law for the following reason.(See.7031.5.Businessand Professions PERMIT ISSUANCE 10.00 VALUATION g/FT.
x `408 Code:Any city orcomtry which requiresa permit to construct,alter,
R R ¢° improve,demolish,or repair any structure,prior to Its issuance,also ELEC.CONTR. LIC.NO. ELEC.
a, requires the applicant for such permit t0 file a Signed statement that TOTAL PERMIT T
a w m he is licensed pursuant to the provisions of the Contractor's License
F z i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and Al Q0�
¢ o the basis for the alleged exemption.Any violation of Section]031.5 OTV. PLUMBING PERMIT FEE
STORIES TYPE CONSTR.
u 3,m by any applicant for a permit subjects the applicant toa civil penalty ALTER-): ALTERVENT-WATER (EA.) 5.00
of not more than five hundred dollars(5500)-):
❑ I,as owner of the pmperty,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 such work - FIXTURES-PER TRAP 5.00 50,FT.FLOOR AREA TOTAL ACREAGE
himself or through his awn employees,provided that seen orm"e-
. mems ore not intended or offered for sale.If,however,the building GAS-EA,SYSTEM-1 1 NC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner-
builder will have the harden of proving GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
that he did not mild or am- RE IND BUILDINGUSEUSEPB Other
`TcV purpose of stria.). INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑
I,as owner y, the construct
he exclusively contra,ing with
II cuntranurs to construct the project ISec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
d o(casinns 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 anch projects with a contractut(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ l am exempt under Sec. ,B&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner) " ' Date s-46,4(' WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
1 hereby affirm that I have a certificate of consent to self-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.L
Policy No. Company
O ❑ Certified ropy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is filed with the city inspection dirision. MISC- REFER TO ORD.
F O Applicant Y❑ No Y ❑ N❑
CCN CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO, PLG.
0- Z (This section need not he completed if the permit is for one TOTAL Y❑ N❑ v ❑ N❑
U O hundred dollars(S100)or less.)
I certify that , the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
U. 1- mit is issued, I shall not employ any person in any manner so as to
O w become subject to the Workers'Compensation Laws of California.
y Date npphcum ALTER OR ADD TO MECH. 5.00 BUILDING
>_ m NOi'IC17 1f0 APPLICANT': IL after making this Certificate of Ex- !
F Z e,ption,you shoold became subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. - AIR HANDLING UNIT(TO 10,00DC.F.M.) 4.00
-CONS'fRUC'f]ON LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.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.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00
' Lender's Name HEATING UNIT 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information n correct. I agree to comply buildith ng
all city and county BOILER-COMP 13 H.P.Or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction. and
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP(Over 100,000 BTU)SEE FEE BCH. MECHANICAL
(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(be
grantinq�f this pennif. � / MECH.CONT. LIQ NO. MECH:-
1 - `(/ TOTAL TOTAL Ob
ignatnre of Applicant/Contractor Date /.
�J INSPECTOR COPY