9266 APPLICANT TO FILL IN INFORMATIONVVXJIIN RED LINES - USE BALL POINT PEN ONLY
•� BUILDING PROJECT IDENTI FICATI_t�' APPLICATION & PER t PERMIT NUMBER
BUILDING ^
ADORES ' 0✓'/ /1�
9266
ING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME xdwxe PHONE OTV. ELECTRIC PERMIT FEE
CONTR C OR3
OUTLETS-SWITCHES-RECEP 10.00/1.00 G
LIGHTING FIXTURES 10.00/1.00
r,DN ACTOR�s APPLIANCES-RESIDENTIAL 4.00
AD ESS
GI� {,/`�� PHONE 21 PANELS 10.00 DATE OF APPLICATION
CHITELT OR PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5.05' PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 PAIM
AEssS SMOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 JUL 121985
Doo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 /s♦ ( (s��ppr}gyp
a v, I hereby affirm that I am licensed under provisions of Chapter 9 CItYJtACkN PC)
w< vW6i (commencing with Sectioqq 7000)of Division 3 of the Busijne's's�and BLDG. ELECT. PLG. MECH.
D z Professions CodeGml.lrRL¢ense is in full(ser a.� ❑
z o at License Class ��ZZJJ��// Lic.Nimbi, ❑ ❑
9 m-O D.te Cmanctor
¢ m E J BU ILDIN E MIT
¢ ¢ w¢ OWNER-BUILDER DECLARATION INFO ATION
a o,.ta MISC.- REFER TO ORD
X ;u y 1 hereby affirm that I um exempt fmm the Contraetor'S License VAWATIO $/FT.
q ..o a Law for the following reason.(Sec.7031.5.Business and Professions -PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
ac to
¢0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
-O LL requires the applicant for such permit to file a signed statement that TOTAL JIB T TO
w$ he is licensed pursuant to the provisions of the Contractor's License
HiQ Law(Chapter 9(commencing with Section 7000)of Division 3 offle
s i O Business and Professions Code)or that Ile is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢ H$ the basis for the.11,ed exemption.Any violation of Section 7031.5 1 5 E E CONSTR.
a. by any applicant for a permit subjects the applicant t...wil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.0(
of not more than five hundred dollars(55000.):
❑ 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 Ole 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 SQ FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such imProve-
formsarenotintendedorofferedforsale.ll',however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, . .) 2.
the owner- GAS-EASYSTEM-OVER 4(EA.) BUILDING USE
builder will have the burden of proving that he did not build or im- E IND CON PB Omar
pruvc for purpme of sale.)' 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 SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Common,',License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts 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.
❑ 1 am exempt under Sec.-.B&P,C.for this WATER HEATER W/VENT 6.00
tWSon
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE N0.
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 IhercolIS 31 Lob.
Policy No. mpa
Q C- led to is e t d FIRESPRINK ENERGY T-24
Z Z ertd icit c p inspection division. MISC.- REFER TO ORD.
0 Applicant- Y ❑ N❑ Y ❑ N❑
CC rn CERT'[FICA'I F 01'Ii XEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LLI > COMPENSAT'ION INSURANCE PLG.CONTR. LIC.NO. PLG. /
d [D ❑ ❑ ❑
0 This section need not be completed if the permit is Rx one TOTA Y N Y N
Z:) Z hundred dollars($100)or less I
-U O I certify that in the performance of the work for which this per- OTV. MECHANICAL PERMIT FEE FEE SUMMARY
EL H mit is issued,I shall nal employ any person in any Inannca so as m
U become subject to the Workers'Compensation Laws of California.
O w Dare Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>_ ED NO'T'ICE TO APPLICANT: If,after making this Certificate of Ex-
F Z 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
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10WOC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10OWC.F.M.) 6.00 SEISMIC FEE
I hereby affirns that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
theeCvrmance of OIC work for which this permit is issued(Sec. MICROFILM
3097, HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that l have read this application and stale 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-OOMP(3 H.P.or 100,000 U.) 00
hereby aullorve representatives of this city to enter upon the BOILER-COMP(Over100,000 BTUI B.T.SEE FEE 6.SCH. MECHANICAL
above-mentioned properly for inspection purposes.
(we) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and ..,eases which CONST.TAX
may in an ay a against said City in conscyue ce of the PERMIT ISSUANCE 10.00
g 1 is nil. MECH.CONT. LIC.N0, MECH.
7 TOTAL TOTAL
S na of A Iicanr/Contractor ate
OFFICE COPY