9395 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALAIWPEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON _ PERMITNUMBER
BUILDING APPLICATION & PERMIT
ADORE" 1 a, FE N iK 9395
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S NAME 4 �0'- Qry ELECTRIC PERMIT FEE PLAN CHECK VALIDATION
PHONE Q j
NAA1eRAcroR UTLETS-SWITCHES-RECEP 10.00/1.00
_IC,NO LIGHTING FIXTURES 10.00/1.00 ,
naoeess T0P3 PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECTOR PLAN(OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.ND. SIGNSTRANS. 3.00
ADDRESS ENG. SPECIALCIRCUIT 5.00 PE ATION
ZIP TEMP.METER OR POLE INS. 20.00 JUL, p O
APPLICANT a MOTORS SEE FEE SCH. 2 S 1985
SERVICE CHANGE 20.00
w o o LICENSED CONTRACTORS DECLARATION' TEMP.POLE 30.00 City Of CUaert;70
a D s~a I hereby affirm that I am licensed under provisions of Chaplcr 9
Haw (commencing with Section 7000)of Division 3 of the Business and ISSUANCE DATE
BLDG.
F - Professions Code,and my license a ELECT. MECH.
nin full force and effect. E] 1:1 ❑
i r`A License Class Lin.Number
o
m r Ua¢ Comracmr
Q Y 3 J
a ¢ w 4 OWNER-BUILDER DECLARATION BUILDING ERMIT
O U MISC.- REFER TO ORD INFOR ATI ON
w g 0 N I hereby affirm that I am exempt Isom the Contractor's License VALUATION S/FT.
u o j Law for the following reason.(Sec.7031.5.Bee essand Professions 10.00
- PERMIT ISSUANCE
COAG Any a, at 4mulish countypair my structure p riot to cronsua ce,also
O improve,demolish,or repair any structure,prior to Its issuance,also ELEC.CONTR. LIC.NO. ELEC.
ii: O u requires the applicant for such permit In file a signed statement that TOTAL
n w w be is licensed pursuant to the provisions of the Contractor's License PERMIT TO
Fi > Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
s x 'e Business,and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
I $ the basis for the alleged exemption.Any violation of Section 7031.5 0 IES TYPE CONSTR.
i 3 - by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars 0500t) ALTER-DRAIN& VENT-WATER (EA.) 5.00
❑ 1,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 I,not
intended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code The Contractors 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.
.cols are not intended or offered for sale.u;however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
imm
proveent is sold within one year of completion,the owner.
%P�,Icssicps
r will have tht burden of proving that he did not build or air- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
Io r purpose of talc.). IND INDUSTRIAL WASTE INTER. 30.00 ON
I,as owner of the property,he project
exclusively contracting with
contractors to The
the project(Sec. 7044, Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
Cale:The Contractor's License law does not apply
to inowner of property who builds improves thereon.and who LAWN SPRINKLERS-OVER 5 IEA., 1.00
contracts for such projects with a contrtr actors)licensed pursuant to
the Contmaori License law. SEWER-SAN ITAR V-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
/"`_X
exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00 r
aw`
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC FILE N0.
WORKERS'COMPENSA'I'ION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a ne,tifcale.1 consent to all-imunc,
r a certificate of Workers'Compensation Insurance,or a cerlit red ZONING ENG.SITE NO,
copy lhcreafl Sea3800,Luh.C.).
Policy No. Company
❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-Z4
Z 2 ❑ Certified copy' is filed with the city inspection division.
FO Applicant MISC.- RE ER TO ORD. Y ❑ No Y Nr
�.y CERTIFICATE OF EXEMPTION FROM WORKERS' PERMtf ISSUANCE 10.00(,# FLOOD ZONE L.U.C.
LU COMA.COMPENSATION INSURANCE PLG.CONTR. LIC.NO. TOTAL y❑ N� A N�
CL o Trhie section need col be completed if the permit 6 for one
::) = hundred dollars IS 100)or les.)
U O 1 certify that in the perlormanec of the work for which this per- CITY MECHANICAL PERMIT FEE FEE SUMMARY
LL U mil is issued,I shall not employ any perwn in any manner so as to
(become subject to the Workers'Compensation Laws of California.
ED Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>_ to NOTICE TO APPLICANT: If,after making this Certificate of Vs.
caption,you should become subject It)the Workers'Compenedinn APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
U such provisions or thispermitshall be deemed revoked. AIR HANDLING UNIT(TO 1OPWC.F.NL) 4.00 FEE
CONSTRUCTION LI:NDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.K) 6.00 SEISMIC FEE
I hereby affirm that there B 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.). - HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lenders Address HEATING UNIT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
I ecHify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information Is correct.I agree ti
comply will,all city cti county
ordinances and state laws Palating m building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
hereby authorize representatives of this city to enter upon the BQILER-COMP(Over 100,000 BTU(SEE FEESCH.
abuvnmentioned property for inspection purposes. 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 10,00JCOTST.TAX
may in any way accrue against mid City in consequence of the
ling Of lhi e Z 5 MECH.CONT. LIC.NO. TOTAL
V OTAL
Signature of A pillitant/Contractor Date
/ , OFFICE COPY