9235 APPLICANT TO FILL IN INFORMATION.WITHIN RED LINES - USE BALL POINT PEN ONLY
• PERMIT NUMBER
BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT
RmLmSS 9235
ADDRESS BUIL
33 $vIT� IDDING -ELECTRICAL-PLUMBING-MECHANICAL
6eb�frv6e�
OWNER'9 PLAN CHECK VALIDATION
NAME ROME OENVb-�-Y Pf72 ^rT PTY. ELECTRIC PERMIT FEE '
PHONE
NANTRACTORsUTLETS-SWITCHES-RECEP 10.00/1.00
NAME
Ot316N PpLII%/D SWR:> rAS LIC.No.46 0Q72 ILIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S 10i (MBb•Wt-. PNB [APPLIANCES-RESIDENTIAL 4.00 W
ADDRESS
u �i PHONE PANELS 10,00 DATE OF APPLICATION
ARCHITECT
OR
PANELS (OVER 200 AMP)
ENGINEER 2000 PLAN CHECK FEE P.C.NO.
-
EN3.00
LIC.No. SIGNS TRANS.
ARCH,OR ENG. 5.00 PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT /f
ZIP EMP.METER OR POLE INS. 20.00
APPLICANT'S MOTORS
ADDRESS
SERVICE CHANGE 20.00
w o O LICENSED CONTRACTORS DECLARATION TEMP.POLE 3 !0
rt u U I hereby affirm that I am licensed under provisions of Chapter 9lei ISSUANCE DATE
wa w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F w z Professions Code,and y license is in full force li .� C =L .Ge ❑ C-1 ❑
z o,�,- License Class Lic.Number / �. LIS,
9 Date Contractor_ L�
< T F G �,7,..r,. D JG
¢ w OWNI7R-BUILDER DECLARATION BUILDING PERMIT
REFER ORD INFORMATION
w3 m I hereby affirm that I am exempt from the Contractor's License MISC.- l VALUATION $/FT.
HuoJ Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE .1690 N
Code:Any city or county which requiresa permit Io construct,alter,
2 Q Q 2O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. LEC. Ov
i - O u requires the applicant for such permit to file a signed statement that C TAL r PERMIT TO
X $ he is licensed pursuant to the provisions of the Contractor's License C�L .0-
Law o
H z i (Chapter 9(commencing with Section 7000)of Division3 of the , '� L
a Business and Professions Code)or that he is exempt therefrom and PTV. PL BING PERMIT FEE
$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant toa civil penalty gLTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages asBACK FLOW PROTECT.DEVICE 4.00 OCG 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 SO.FT.FLOOR AREA TOTAL ACREAGE
• meets are otinthd.d.r employees,provi,ed however,(lie
improve GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
himself
are not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Orbe,
prove for purpose of sale.), INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ 13licensed 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 not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with A contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 TRACT N0. PARCEL NO.
the Contractor's License Law.
❑ lamexcmptunder Sec. .B.&P.C.(orlhis WATER HEATER W/VENT 6.00
reason
Owner Data WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified _
copy thereof(See 3800,Lah.CI
Policy No. Company
O ❑ Certified c PY i hereby turn had. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified c r' is ile i I the city inspection division. MISC.- REFER TO ORD. Y ❑ NE] Y ❑ N❑
p Applicant
1"' y PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
UJ CISRT ICCOMPE liAI ION 101 ROM WORKERS'
W COMPENSATION INSURANCE PLG.CONTR. LIC.rvo. PLG. L Y❑ N❑ YR N❑
LL O (This section need not he completed if the permit is for one TOTA
D Z hundred dollars IS 100)or less,
V O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
U. F mil 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. BUILDING
Date Applicant ALTER OR ADD TO MECH. 5.00
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
? 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
C..1 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000CFAL) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=CEM.) 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. HEATING UNIT(TO 100,000 B.T.U.) 6.00 MICROFILM
3097,Civ.C,.
Lenders Name HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
1 certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
. ordinances n correct. I agree to comply with all city and county BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00 PLUMBING
information
and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP Over 100,000BTU)SEE FEE SCH. MECHANICAL,
above-mentioned 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 a w y accrue vgai sl said City in consequence of the
grantin f K permit. MECH.CONT. UC.NO. MECH.
TOTAL TOTAL
Sign of ApplicantlContract r to
OFFICE COPY