9435 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
. BUILDING PROJECT IDENTIFICATION , PERMITNUMBER
k BUILDING APPLICATION & PERMIT
ADDRESS
/ q
1 l0 1S VYI51Y'I G . BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
9435
OWNER'S PLAN CHECK VALIDATION
NAME TY. ELECTRIC PERMIT FEE
0� CNAME
ONTRACTORS OUTLETS-SWITCHES-RECEP 10.00/1.00
LIc.NO, LIGHTING FIXTURES 10.00/1.00
aoo ese oR's APPLIANCES-RESIDENTIAL 4.00 -
PHONE PANELS 10.00 DATE OFAPPLICATION
ogcHITECT PANELS (OVER 200 AMP) 20,08 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO, SIGNS TRANS. 3.00
Doo ESSs ENG. SPECIAL CIRCUIT 5,80 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT'S
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
O
It 2 f/-7
F
02 LICENSED CONTRACTORS DECLARATIONTEMP.POLE 30.00 6 0 l
¢u w 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
H <w (commencing with Section 7000)of Division 3 of the Business and - BLDG. ELECT. PLG. MECH.
H y z Professions Code,and my license is in full force and effect.
z 0 w License Class Lia Number
o W
w H Date Contractor ❑
a -i
OWNER-BUILDER UECLA RATION BUILDING PERMIT p
s o s INFORMATION
w g y I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
LL VALUATION
u O j Low for the following my w.(Sec.7031.$,erminessaod Professions $/FT.
H - PERMIT ISSUANCE 10.00
w i f Code.Any city li county which reqstructure,
riort toconssuanc.also
¢ ¢ ¢O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
m LL requires the applicant for such permit t0 file a signed statement that TOTAL
W he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
HiQ Law(Chapter 9(commencing with Section 70000of Division 3 oflhe �L-d G"'
f s o Business and Professions Code)or that he is exempt tlmrcfnnu and GTY. PLUMBING PERMIT ' ' FEE
¢ H$ the basis for the alleged exemption.Any violation uf8ecliun 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars($500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 Oee.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended Or offered for sale (Sec. 7044, Hasiness 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 SO.FT.FLOOR AREA TOTALACREAGE
• himself or through his own employees,provided that such....prove- w.
meats are 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-
builder will have the burden Of proving that he did not build or int- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 3000 RES IND CON pa Other
❑ 1,as owner FT the property,am exclusively contracting with .
licensed contractors to construct the project(Sec. 7044,BusinessLAWN 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 therenn,:md who LAWN SPRINKLERS IEA.1 1.00
contracts for such projects with B contructoRs)licensed pursuant to
The Contractor's License Law. SEWER-SANITAR V-S O MEA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P,C.for this WATER HEATER Vlf VENT. 6.00
\V/ reason �p�
Owner - Date�T-W WATER SYSTEM - 5.00 ACC.OATE ACC.FILE NO.
WORK E RS'COMPENSAT' NDECLARATION WATER TREATIN , O )PI 5.00
I hereby affirm that I have a certificate DI consent to sell'-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.j. /
Policy No. Company
O ❑ Certified copy is hereby furnished. ' FIRE SPRINK ENERGY Tp4
Z Z ❑ Certified copy is filed with the city Inspection division.
F- O Applicant MISC.- V REFER TO ORD. Y N❑ Y ❑ N�
CC y CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZOrvE. A.L.LED C.LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
0' O (This section need not he completed if the permit is for one TOTAL / Y� N❑ y No
::) Z hundred dollars IS loo)or less.)
U O I certify that is the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY'
LL 1- mil is issued.I shall not employ any person in any manner so as to
O w become subject to the Workers'Compensaliun Laws of California.
IS. Date Applicant ALTER OR ADD TO MECH. 5,00 BUILDING
} 2 NOTICE TO APPLICANT: If,alter making this Certificate of Fx-
♦- _ emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000 C.F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IO,ODOC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a crostRi"ion lending agency I'or EXHAUST HOOD(WITH DUCT) 5.00
The performance of the work for which this permit is issued(Sec. MICROFILM
3097,CIV.O.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and slide that the above VENTILATION FAN (SINGLE) 4.00 J
information is correct I agree to comply with all city....
tructionnd couandnty BOILER-COMPO H.P.or 100;000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building cons .
hereby authorize representatives of This city es enter upon the BOILER-COMP(Over'100,000 BTU)SEE FEESCH. MECHANICAL
hereby
aboveauthorize
property representatives
inspection of this
purposes.
(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 10.00 CONST.TAX
may in any way accrue agai t said City in consequence of the
granlin this perm r MECH.CONT. LID.NO. MECH.
TOTAL TOTAL
Signature of Applicant/ racmr [)ate
OFFICE �„�-