9239 APPLICANT.TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
aUILOINc APPLICATION & PERMIT
ADOR 9239
UILDING-ELECTRICAL PLUMBING-MECHANICAL
ovmEn' /•/]� O� ELECTRIC PERMIT FEE VPLAN CHECK VALIDATION
g 441"A �e E "'iiff``�� .
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NAME ACTORS UTLETS-SWITCHES-RECEP 10'00/1.00
LIC.No, LIGHTING FIXTURES 1$00/1.00
CONTRACTORS APPLIANCES 4.00
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
onncHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
moo ESS E "C SPECIAL CIRCUIT 5.00 D PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 n
ADDRESS MOTORS CH. j Q (mac
SERVICE CHANGE 20.0,0. (�
wa¢ Za LICENSED CONTRACTORS DECLARATION TEMP.POLE �3 :00
< u w I hereby affirm that I am licensed under pmvisians of Chapter 9 ISSUANCE DATE
N
< w
(commencing with Section 7000)of Division 3 of the Business and LG EDH.
F m z Professors Code,Imd my license is in full force and effect. - i yl oY
z o m n License ClassLic.Numhef � 5T. P- �
9 a I- w Date Contractor �� D PAP.
ppW�
¢ a a < OWNER-BUILDER DECLARATION BII�FOHMA'fl(]N"TIIO
K
H 1 hea by affirm that 1 am exempt from the Contmcmr's License MISC.- REFER TO ORD
H N O 4 Law for the IcAlowing reason.(Sec.1031.5,Busineavaod Professions PERMIT ISSUANCE a;�0 `/ALUATION SIFT.
Cade:Any city or county which requiresa pemlit to constmcl,.1111,
a¢o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NU. ELEC.
Ou mgoiees the applicant for such permit to file a signed statement that TOTAL 6
E
he is licensed pursuant to the provisions of the Contractors License PERMIT TO
Fza Law(Chapter 9(commencing with Section 7000)of Division 3 ofth<
4 D Rusiness and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢ 1- o the basis for the alleged exemption.Any violation of Sccti.n 7031.5 STORIES TYPE CONSTR.
aby any applicant for a permit subjco3 the applicant too civil penally ALTER-DRAIN -WATER IEA.) 5.00
Of not more than five hundred dollars(5500).1:
❑ I,as owner of the property,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 (See. 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 themon,and who docs such work FIXTURES-PER TRAP sO n.aooR AREA 7orAl ACREAGE
himself or through his own employees,provided that such improve-
mentsare not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within One year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of mile.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB ower
❑ I,as owner of the property,am exclusively contracting with
licensed contractors to Construct the project(Sea 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Cale The Contractor's License law does not apply
10 an owner of propertywho builds or improves thorcon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
Contracts for such projects with a contrxctogs)licensed pursuant to -
the Contructor'sLicense Law.. SEWER-SANITARY-STORM EA.2001t/10.00 TRACT NO. PARCEL NO.
❑ I am exemp oder Sea IT&P C.for th'y WATER HEATER W/VENT 6.00
reason +CLrt.
Owner t = WATER SYSTEM ACC.DATE ACC.FILE NO.
WORK E RS'CONPEN'SATION DECLARATION WATER TREATING EO 1Wt;!bb
I hereby affirm that I have a ccnifcate of consent to self-insure.
Or a acnificalc of Workers'Compensation Inwrancc,or a certified 1 ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.). CV
Policy No. Company rid
0 ❑ Cenifed copy is lunch,famished' -FIRE SPRINK ENERGYTZ4
Z Z 0 Certified copy is filed with the city inspection division.
FO Applicant MISC.- REFER TO ORD. YE] N Y ❑ NE]
CCH CERTIFIC T1s OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE Y0.00 t.1 FLOOD ZONE A.LU.C.
L COMPILNSATION INSURANCE PLG.CONTR. LIC.NO. PLG,
CL O 1'fhis section need not be completed if the permit is far one TOTAL Y N� Y ❑ N❑
::) Z hundred doBars(5100)or less)
U O' I certify that in the performance Of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued, I shall not employ any person in any manner so as to
become subject to the Workers'Compenmlion Laws of California.
0 a Dam Applinm ALTER OR ADD TO MECH. 5.00 BUILDING
} Co NOTICE TO APPLICANT: If,after ranking this Ccrtifieulc of Ex.
F Z
sorption.you should become subject to the Worken'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MCF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MOCF.M.) 6.00 SEISMIC FEE
1 hereby affirm Had there is a conatructiun lending agency 1'Or EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is Romed(Sec. MICROFILM
3097,Civ.CA HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 1 DO,000 B.T.U.)9.50
Lender's Addreu ELECTRIC �6 �
1 certify that I 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 o-V
ordinances and state laws relating to building construction, and BOILEFLOOMPO H.P.Or 100,000 B.T.U.) 6.00
hereby.authorize representatives of this cityhr enter Honor the BOILER-COMP (Gvnr 11X1,000 BTU)SEE FEE BCH. 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 mway ay ac a against mid City in consequence Of the
g n ago f I perm MECH.CONT. LIC.NO. MECH.
��J TOTAL TOTAL /f0
S gnature W Applicant onlractor U�
OFFICE COPY /