9182 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJE�DENTIICATION _ PERMIT NUMBER
ODILDING APPLICATION & PERMIT 9182
ADOgEss BUILDING - ELECTRICAL-PLUMBING -MECHANICAL
c- R c
�L,p .T.'T'I"rL, L'c�f,.y PLAN CHECK VALIDATION
DWNEq'S ; v- p Y,C }F Jyn'✓„�`-' a h
"MEOTY.'. f v�P- ELECTRIC PERMIT lw pa`.FEE '
s. IN/ PHONE l7 S�S �!':v ..'ELECT R..
��• CONTRA`TORsUTLETS-SWITCHES-RECEP 10.00/1.00
LID LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S PPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEEF.C.NO.
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRESS ENO' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP. METER OR POLE INS. 20.00 f
APPLICANTS MOTORS SEE FEE SCH. / �f
ADDRESS [[[
SERVICE CHANGE 20.00 l
°w o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 -/•�
F u ix 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
(Commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
E. 0 z Professions Code,and my license is in full force and effect. El ❑ ❑ [3z 0`Pi` - Lieeruse ClassLic.Number
0 z o Date Contractor
`a f '" BUILDING PERMIT c ^�a
E Ic w OWNER-BUILDER DECLARATION S'�j4-A,INFORMATION M
K o e. 1 hcreb affirm that I am exempt from the Contractor's Licenu MISC.- REFER TO ORD
u, 3 u ,�„ y p VALUATION
w o a Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 10.06-
0 Any city or county which mgWresa permit to construct.alter,
� QQp ImprOVO.demolish,or repair any stracturc.prior to its issuance.also ELEC.CONTE. LIG NQ ELEC.
- DLL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
whe is licensd pursuant to the provisions of the Contractor's License
r
L.-(Chapter 9(Commencing with Section 70000o1'Division3 ofthe _ 's,'•' " ' - ` �'
z Q Business and Profesns sioCode)or that he is exempt therefrom and QTY: PLUMBING PERMIT ,'171'1 :TFEE";.
z 2: the basis for the alleged exemption.Any violation of Section 7031.$ " '4'�'r. ` r " - -.>.:'- -.'e s t STORIES TYPE CONSTR.
a ; - by any applicant for a permit subjects the applicant ton.civil penalty ALTER-DRAIN -WATERIER.) 5.00
of not mom than five hundred dollars(5500).):
❑ 1,as owner of the property,or my employes with wages as BACK F LOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole cmeperuatime,will do 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 doe,not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SCL FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees.provided that such improve-
; ments arc 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 BUILDING USE
'-' builder will have the burden of proving that he did not build or ire- RES IND CON PB Ouse.
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044.Business LAWN SPRINKLER$-1 INC 5 V.B. - ASS SSORS 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 contrachouds)licensed pursuant to SEWER-SANITARY-STORM EA.2001t/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
0 I am cxemplunder Sea .B.&P.C.for this WATER HEATER W/VENTqIp 6.00
rumor
owner WATER SYSTEM 5.00
ACC.DATE ACC.FILE N0,
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQU
AVIIN E 4 195Irw
I hereby affirm that I have a certificate of consent to Siff-insure. ZONING ENG.SITE NO.
or a certificate of Workers Compensation Instances.or a certified .y
copy thereof(Sec.3800.IAb.C.I. f_Cupert=
IIRO
Policy No. Compan)' ,{
O ❑ Certified copy is hcreb)'furnished. 6 FIRE SPRINK ENERGY T-24
Fp Applicant❑ Cerified copy h fled with the city inspection division. MISC.- EFER TO ORD. Y ❑ rv❑ Y ❑ No
y CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 4698 60FLOODZONE A.L.U.C.
LLI > COMPENSATION INSURANCE PLG.CONTE. LIC,NO. POTAL LG. Y E] INE] V E] N❑
CL Z T
(This section need not be completed if the permit u for one Q _
hundred dollars(S I00)or he.I
U O I certify that in the performance of the work for which this per OTY.-. MECHANICAL PERMIT- FEE Z' _FEEISUMMAR, "• '
L.L U mit is issued.I shall not employ any person in any manner so as to
O W become subject to the Workem'Compcnsatiun Laws of California. BUILDING
Date Applicant ALTER OR ADD TO MECH500
>_ N NOTICE TO APPLICANT: If,after making this Cenifieau of Ex-
. .
? emption,you should become subject to the Workers Compen.ution APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions o1 this permit shall be deemed mvoked. AIR HANDLING UNIT(TO 70,000 C.F.MJ 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.F.ML) 6.00 SEISMIC FEE
I hereby affirm that there is a eonw.clion Iendinp 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 HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lenders Address ELECTRIC
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
inrlr:mat ion is Correct.I agree to comply with all city and county PLUMBING
anees and stale laws relating to building construction, and BO
dmILER-CD P(3H.P-or100,000B.T.U.) 6.00
�hereby authorize representatives of this city to toter upon the BOILER-COMP (Over 10,000 BTU)SEE FEE SCH. MECHANICAL
ebove-mencch1d property for inspection Purposes.
(Wye) agree lD gave, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities.judgments, costs end expenses which CONST.TAX
may in any we aurae a PERMIT ISSUANCE 10.00
y �/1 Faint/ said City in co sequence of the
grantlrlP�f thi en»itn MECH.CONT. LIC.NO. MECH. - .
11
-fI �/ 6 TOTAL -1 TOTAL`' '
./h Signature of Applicanticon.Eei Date -
OFFICE COPY