9454 ANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
�-'k{^.,�.vJ LDING PROJECT IDENTIFICATION APPLICATION & PERMIT - PERMIT NUMBER
OUILD°R
I v �/7j L �/� ( L'GT BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 9454
...ER's / e.g u " PLAN CHECK VALIDATION
4_FEE
NAM
CITY. ELECTRtIC 4'PERMIT 'lisb g,UFEE"
PHONE
NOBTRAcrons OUTLETS-SWITCHES-RECEP 10.00/1.00
L t� LIGHTING FIXTURES 10.00/1.00
CONTRACTOR• ��7 �/� APPLIANCES-RESIDENTIAL 4.00
12/�/y/�
Z W !/G PANELS 10.00 DATE OF APPLICATION
OR
RCHIiECi PANELS(OVER 200 AMP) 20.00 PLAN CHECK FEEP.C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
noo Ess ENO' SPECIALCIRCUIT 5.0Q PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20,00 ^ J
^
APPLICANT s 5� A A r MOTORS SEE FEE SCH. � l/.10�(^,'„p+~�
�fL••'` SERVICE CHANGE 20.00 rX�, (/
w O o, LICENSED CONTRACTORS DECLARATION TEMP,POLE 30.00 0
le u 1 hereby affirm that I am licensed under provisions of Chapter 9 1
Z ISS 'NCE DATE
(commencing with Section 7000)of Division 3 of the Business and
H i Professions Co a license is in full(or a e( -t BLDG. ELECT. PL❑G, MECH.
License Class Lie.Number
O z H w Date Contractor
Q Y $ J
M a w at WNER�BUILDER DECLARATION _ ; '.BUILDING PERMIT,;'
xoWU MIS0.- REFER TO ORD ' ;'INFORMATION�t
; LL u I hereby affirm that I am exempt from the Contractor's License
H N U- J Law for the following reason.(See,7031.5,Businessand Professions PERMIT ISSUANCE VALUATION S/FT.
Code:Any city or county which requires a permit to construct,alter, 10.00
a 5 ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
u y 0,u. requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
X m m he is licensed pursuant to the provisions of[he Contractor's License
HZ Q Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe lT
2 E D Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT ?FE
ICH$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant fora permit subjects the applicant toacivil penalty ALTER-DRAIN&VENT-WATER IEA.) 5.00
of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOPROTECTDEVICE 400 Occ.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not . .
-
intended or offered for sale(Sec. 7044, Business and Professions DRAIN LOOR ROOF,AREA,CON D. 5.00 CjO...
Cade:The Contractor's License Law does not apply to an owner el'
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP S.00 6D.FT.FLOOR AREA TOTAL ACREAGE
himself re of rote his own employees,Provided that such improve.
o improvement tended oroffered
on year o((,however,the building GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement is held within one year of completion,the owner.
or
builder will have the burden of proving(hat he did not build er ins- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
Prove foronof sale.). INDUSTRIALWASTE INTER3000 REs IND CON PB Othe.
❑ I,ass owwnerer . .
of the properly,am exclusively contracting with ❑ 13 11 ❑
licensed contractors Io 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 IEA) 1.00
contracts far such projects with a contractor(s)licensed pursuant to -7-
o
tlmContractor'sLicenseLaw. SEWER ANITARY TO RM EA.200ft/10.00 a TRACT NO. PARCEL NO.
❑ 1 um exempt under Sec.-,R&P.c.for this WATERreasom ATER HEATE E T 6.00
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TR TING IP, 5.00
1 hereby affirm that I have a certificate ofconsent to self-iowne,
or a certificate of Work mpens tion Insumnc or a ce I(ied jy ZONING ENG.SITE N0.
Copyr � � l O Up8
ffillid
Polic anyE4
❑ e Ifiedcopylshereb fu nished. FIRESPRINK ENERGY T-24
Z 2 Cenifie c pY II with se city inspection division.
.� O A ant MISC.- REFER TO ORD. Y❑ NEJ Y 0 N[:]
CCN - CERTIFICATE OFEXEMPTION PROM WORKERS' PERMIT ISSUANCE 10.00O FLOOD ZONE A.L.U.C.
W COMPENSATION INSURANCE PL Pr O PLG.
CL Z ('I his section need not be completed If rile permit is for one /i i'� TOTAL �O Y 11 N V R NEI
hundred dollars(5100)or less.)
U O I certify that in the performance of the work for which this per- GTV. MECHANICAL PERMIT FEE
FEE SUMMARY
LL I- mil is issued,I shall notemploy any person in any manner so as to
D become subject to the Worken Compensation Laws of California.
0 y Datc ApplicantBUILDING
>_ r7 NOTICE TO APPLICANT: If,after making this Certificate of Ex, ALTER OR ADD TO MECH. 5.00
)... ? 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 10,000C.F.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10PWC.F.M.) 6.00 - SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
Om 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
i Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 y
information corner. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING 3Qa
ordinances
s and urate laws relating to building construction, send
hereby authorize representatives of This city to enter ,on
the 801 LER-COMP(Over BTU(SEE FEE SCH.
above-nsentioned property for inspection purposes. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against lig ilities,judgments, Costs and oxpenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way ac me against said City in c nuq once of the
gr tin of I p rad 4711- MECH.CONT. UC.NO, MECH.
O TOTAL TOTAL
alurc of pplicanl/Contractor Data
OFFICE COPY