9347 HrNCICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING OJECT 5ENTI FICATION PERMITNUMBER
BUILDING APPLICATION lit PERMIT 9347
ooRE
UILOING-ELECTRICAL-PLUMBING-MECHANICAL
N1MERa ' >_ Y.�f{ -.M�`�p'f'*._ s%� ''. " t�`P "a PLAN CHECK VALIDATION
11 ELECTRIC Ev pMY1ii�Ynw'' MAN
• �.i�IJ ICI.4 PRONE 7 ^T .' YY C.. rt 1 w�i&_] to.'7''�iNri
cONTRAcronsUTLETS-SWITCHES-RECEP 10.00/1.00
NAME
BLOODFk)VIJb C-(gCTA}C uC.ND, 4415195 LIGHTING FIXTURES 10.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADDRESS
23l 5 . MOrik"04') PHONE 286�b9D PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.
DRiOR SS ENO, SPECIAL CIRCUIT &OO PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH. PAID
ADDRESS
SERVICE CHANGE 20.00
Woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 JUL Z 3 AS
a v 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSU LE GATE
N <i (commencing with Section 7000)of Division 3 of the Business and BLDG. I ECH.
M z Professions Code,B6t y license is in full force `41Y I. IT
❑ ❑
z o`v1' License Class 11 Lic.Number Yz) 73
w De(e '1`2 Contractor L
J A' rA UMNO.P@RMI x ,
¢ ¢w u OWNER-BUILDER DECLARATION r NVOPMATION
I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD TZP
A.rn VALUATION S/FT.
F u O 4 Law for the following reason.(Sec.703 1.5,Businessand Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires permit to construct,alter,
i a < improve,demolish,or rePair any structure,prior to its issuance,atm ELEC.CONTR. LIC.NO. ELEC.
O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
E
$ he is licensed pursuant to the provisions of the Contractor's License 12,
iia Law(Chapter 9(commencingwith Section 7000)of Division 3 oflhe - ,a- fti °• s "` ,5-�x - P '` /
¢ D Business and Professions Code)or that he is exempt therefrom and OTYPLUMBINOIP@R_
the basis for the alleged exemption.Any violation of Section 7031 5 n. .. -. ..- . ` , 1' IVB s STORIES - TYPE CONSTR.
i ; by any applicant for a permit subjects the applicant(as civil penalty ALTER-DRAIN IEA.) 5.00
of not more than five hundred dollars($5001.1,
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sale compensation,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 does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES,PER TRAP 5.00 SM FT.FLUOR AREA TOTAL ACREAGE
• himself re not hrough
ownemployees,for uIc.If,ed that however.the
improve. GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
mems arc nor intended or offered far sale.If,however,the building
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 im- IND CON PB Oln.r
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RV
❑ 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 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 forsuch projects with a contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO, PARCEL NO.
❑ 1'em exempt under Sec. ,B.&P.0 for(his WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate ofconsent to ul&insure. ZONING
or a certificate of Worker'Compensation Insurance,or a certified ENG.SITE N0.
copy themef(Sec.3800,Lab.C.).
Policy No. Company
O O Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z D Certified copy is Bled with the city inspection division. MISC.• REFER TO ORD.
Applicant v ❑ N Y 1:1 No
F' to PERMIT ISSUANCE 10.00
CERTIFICATE OF EXEMPTION FROM WORKERS' FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG CONTR LIC NO PLG. y[3 N❑ V E] N[3CL Z (This section need not be completed if the Permit u for one TOTAL
hundred dollars IS 100)or less.) w ,tsil,v,t r
U O 1 certifythat in the erformance of,the work for which this r F°C s '11 St
LL F mi( is issud,I shall mol employ any Perron in any manner m a�to �Y 1 �`4w ANICAL PERMITy itzW jF@@�':I c
O w becom s e ( (ye Worke 'Co math Law of Califo ;`r • '"� + f• t »'a1E4
y Date " qF Applicant BUILDING
} m NOTICE. TO APPLICANT: If, er king that Certifi ale of W IFS
ALTER OR ADD TO MECH. 5.00
F Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the labor Code, you Inmt forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO io=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0OOOC.FIA) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
309 .Civ.Cz nee of the work for which this permit is issued(5<c. HEATING UNIT TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name
Lender's Address HEATI NG UN IT(OV ER I DO,000 B.T.U.)9.50 ELECTRIC
I 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
ordinances and state laws relating to building construction, and BOILER•COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(Wel 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 any way active against said City in consequence of the
enI of thin Permit �Y MECH.CONT. LIC.NO. MECH. :.;,,:
T!� TOTAL toTa�a,
at of Applicant/ ntractor
OFFICE COPY