9390 APPLICANT TO. FILL IN IN FORMAT19NIVVITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATIONPERMIT NUMBER
aG DANG - 'APPLICATION & PERMIT
ADDRESS. BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 9 3 9'0
/037 ,4✓ENtp.
• OWNER'S -
NAME g x ' " s -IFa y 6.4 ip.;,. 'x PUAN CHECK VALIDATION
PHON O DTV) .,r ^ELECTRIC PERMITg L tyFEE
NACONTRME ACTOR
UT
LETS-SWITCHES-.RECEP 10.00/1.00 Z�•
LIC.NO. LIGHTING FIXTURES 10.00/1.00 '
ADDRESSTORS .,S'N,nny✓q/G. //OP' PPLIANCES-RESIDENTIAL 4,00 /2A +
;D FHONE -7 PANELS - 100016, DATE OF APPLICATION -
ORRCMITEci PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH OR ADDRESS ENG SPECIALCIRCUIT 5.00 • PERMIT VALIDATION
zip TEMP.METER OR POLE INS. 20.00 PAID)
APPLICANT's - 1
ADOREss b MOTORS SEE FEE SCH. � OCTSERVICE CHANGE 20.00 41 11 '90[
J w o LICENSED CONTRACTORS DECLARAT ll TEMP.POLE 30.00 VJ
au uI hereby affirm that I am licensed under provisions of Chapter 9 -
G a n lsstcl�wdfelmrt Mill
(commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. H.
F w i Professions Code,tnd t license is in full fore a 'eft 1-1
❑ ❑
O z f-0 o License Class _ Lin.Number O
,A r Uate Contractor
Q w a
wF u _PE
- '
OWNER-BUILDER DECLARATION BU DING4PERMI,Tf �* J
o eJINFbRkT10NW„ :W
g 1 hereby affirm that I am exempt from the Contractor's LicenseMISC. REFERTOORD
o
4 Law for the following reason.(Sec.7031.5,Businessand Professions VALUATION $/FT.
w PERMIT ISSUANCE 10.00 "'
Ew Code'.Any city or county which requires a permit to construct,alter, -
ac sto improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.No0. ELEC. /�/]
e, a G u requires the applicant for such permit to file a signed statement that 3a TOTAL /T�-+
w m he is licensed pursuant to the provisions of the Contractor's License .PER MIT TO
_
F z i Law(Chapter 9(commencingwith Section 700()of Division 3 ofthc - ' R
m o Business and Professions.Code)or that he is exempt therefrom and QTY." + PLUMBING PERMIT" €$# x & P FEEa#�4
r o the basis for the alleged exemption.Any violation of Section 7031.5
k STORIES TYPE CONSTR.
nam by any applicant for a permit subjects the applicant too civil penalty gLTER-DR-AIN&VENT-WATER IEA.) 5.00
of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CON D. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 50.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 6,00 .
or improvement is sold within one year of completion,the owner
builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
prove for 1,aso neeose of salep - INDUSTRIAL WASTE INTER. 30.00 RE lO ON . O Other
❑ d as owner of the property,he projectexclusivelye contracting wills
licensed contractors to construct the project(Sec. 7044',Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does nut apply
to antr owner of property who buildsorimproves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts is Contraor ctor's
projLicense
with a contractors)licensed pursuant to• SEWER-SANITARY-STORM EA.200ft/10.00.
" file Conhac[or s License Law. TRACT NO. PARCEL NO.
I am exempt under Sea B.&P.C.for[his
rea❑son WATER HEATER W/VENT - 6.00
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPF.NSATION DECLARATION r WATER TREATING EQUIP. 5.00
hereby affirm that I have a certificate of consent to self-Insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy lhersq);(S yin�ajyy ). ,
Policy a �(P„$_F�I{pF4(y
Q ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z Certified p is F 'd with HIS city inspection division.
H p n picant- _ CG'f/YCy - MISC-- REFER TO ORD. Y - N� v � N�
CC T
CERTIFICATE i OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10,00 FLOODZONE A.L.u.C.
LL > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O (This section need not be completed If the permit Is for one, TOTAL Y N Y 0 N EI
� Z hundred dollars IS 100)or less.) _ - - - -
r d+.su:
'J O I certify that In the performance of the work for which this per - � ' q ;;FEE SUMMARY +L
H mit is issued,I slmll.not em to an OTEYi ,-M1G ECHANICAL PERMIT, ' FEE
LL employ y person in any manner so as to - s r, b Y "
O w become subject to the Workers'Compensation Laws of California.
y Date - Applicant ALTER OR ADD TO MECH. 5.00 gBUILDING} W NOTICE TO APPLICANT: If,after making this Certificate of Ex emotion,you should become subject to the Workers'Compensation APPLIANCE 5.00 provisions of the'Labor Code, you must forthwith comply with such provisions er this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00CONSTRUCTION LENDING nC.ENCY AIR HANDLING LINIT(OVER 10=C.F.M.) 6.00 1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the workfor which this permit is word(Sec.
3097,Civ.C.). HEATING UNIT TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATI NG UN IT(OV ER 100,000 B.T.U.)8.50 ELE6TRIC
I certify that l have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county BOILER-CCMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction, and
above-hereby authorize representatives of this city es enter upon [tic BOILER-COMP (Over 100,000 BTU)SEE FEESCH. MECHANICAL
above-mentioned property fotinsp ofth i purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. 'Y
r Cupertino against liabilities,judgments, costs and expenses which ' CONST.TAX
PERMIT ISSUANCE
may in any way accrue against said City in consequence of the - 10.00 ,
�E mg of this permit. nn MECH.CONT. LIC.NO.� MECH.
/ � ,:iiF �O"��'d 5 TOTAL TOTAL
ignamme of Aophcan Contractor Date
OFFICE COPY