C 9426 l
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
+ ERMIT NUMBER
BUILDING PROJECT I DENT FICATION APPLICATION & PERMIT
BUILDING -
AODRESS n
�9 � _�t A.1e f BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 9 4 Z 6'
OWNER'S - PLAN CHECK VALIDATION
"AME
CITY ELECTRIC ELECTRIC PERMIT FEE / 0,
PHONE V
/ corvrflacrofls [OUTLETS-SWITCHES-RECEP 10.00/1.00
J� NAME
5+ee I Cons+SID ND34g2Q LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S PPLIANCES-RESIDENTIAL 4.00
ADDRESS1
1(03 W 11tR4\)es $.U.PHONE 733-4 IPANELS 10.00 DATE OF APPLICATION
ARCHITECT - PAN E LS (OV E R 200 AMP) 20.00 PLAN CHECK FEE C.NO.
P.
OR
ENGINEER
uc.No. ISIGNS TRANS. 3.00
ADR, ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
SS
ZIP TEMP.METER OR POLE INS. 20.00 n
AMOTORS SEE FEE SCH. Q J J
ADDRESS
ESS /
• SERVICE CHANGE r,.n..r 20.00
TEMP.POLE 30.00 �� %'pp
foo LICENSED CONTRACTORS DECLARATION O n^.nC pS
rcto U I hereby affirm that 1 am licensed under provisions of Chapter 9 d V 4 IJ va f 1 1015 CE DATE
Za (commencing with Section 7000)of Division 3 of the Business and BL G:+ aE CT•r ItPLGJ I MECH.
F w re , Professions Code,W my license is in full force and f n. ... ❑ O ❑
License s Lic.Numb i vncpe r
Q m r Date Contractor • G IT
Q y f J
¢ re OWNER-BUILDER DI ARA N INFORMATION
woa ° MISC.- REFER TO ORD
F I hereby affirm that 1 am exempt form the Contractor's License VALUATION $/FT.
F u o a Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 )�/ OQ
Code:Any city or county which requires a permit to construct,alter,
2 rt ¢ improve,demolish,or repair any Structure,prior to its issuance,also ELEC.CONTR.. LIC.NO. ELEC. �1
-o u requires the applicant for such permit to file a signed statement that - TOTAL � x„� PERMIT TO
a w m he is licensed pursuant to the provisions of the Contractor's License
4,M)
g /
Fzr
Law(Chapter 9(commencing with Section 7000)ofDivision3ofthe i ,M) 7e4
¢ Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
rc r o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
i ; m by any applies.,for a permit subjects the applicant toacivilpenally ALTER-DRAIN -WATER (EA.) 5.00
.four marc than five hundred dollars(5500).):
❑ 1,as owner of the property,or my employees with Wages as BACK FLOW PROTECT. DEVICE 4.00 oce.GROUP RES.urv1T5
their$
ole compensation,will Jo 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 SO.FT.FLOOR AREA TOTAL ACREAGE
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-1 INC.4 OUTLETS 6.00
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[hat he did not build or im- RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ has owner of the property,am exclusively contracting with - ❑ ❑ ❑ ❑ ❑
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 not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contmen,for such projects with a contractor(s)licensed pursuant to
the Contractor's License Law. - SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date 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 selhinsum, ZONING ENG.SITE N0.
or a Certificate of Workers'Compensation Insurance,or a certified
copy thereof(See,3800,Lab.CJ,
Policy No. Company
Q ❑ Certified copy is hereby furnished. FIRESPRINK ENERGYT24
Z v ❑Applicant Certified copy is riled with ,he city inspection division. MISC.- REFER TO,ORD. V ❑ N❑ V ❑ N[]= CERTIFICATEOF EXEMPTION FROM WORKERS'
O^
rj n PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.c.
UJ _ COMPF-NSATION,INSURANCE PLG.CONTR. LIC.NO, PLG.
CL O (This section need not be.cmple,ed if the permit is for one TOTAL V[:] N❑ V EJ N❑
o
D Z hundred dollars($100)or Ies5.)
0 O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL f mit is issued,I shall not emplO v y person m any Wanner so as to
U becow b)j���yy',,��tgythe Workers lion L w Ca Torn' . ,fa
0 y DOC /ry"APPLICANT:
I ALTER OR ADD TO MECH. 5.00 BUILDING A
} N NOTICE TO APPLICANT: IG after O g Ce[ificale of Ex-
Z eruption,you should become subject to the kers''Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Cade, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.U0 4.00 `
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10J00DC.RM.) 6.00 SEISMIC FEE Q
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.) 8.00 MICROFILM
3097,Civ.C.).
Lender's Name - 61,12
Lender's Address HEATI NG UNIT(OV ER 100,000 B.T.U.)9.50 ELECTRIC o�
Icertify that l have read this application and state 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(3H.P.or100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP low,100,000 BTU)SEE FEE SCH.1 I 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 whichCONST.TAX
may in'any'way accrue against said City i consequence of the PERMIT ISSUANCE 10.00 -,
r 'ng fthis permit MECH.CONT. LIC.NO. MECH. e�
glas 5 TOTAL TOTAL l�Z/
ol
Signal re of tic [ tractor - Date
OFFICE COPY