9434 Y.�
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
r BUILDING PROJECT IDJENTIFICATION PERMIT NUMBER
ADAPPLICATION & PERMIT
ADDRESS
1601 RP - V KO BUILDING -ELECTRICAL-PLUMBING -MECHANICAL 9434
( OWNER'S PLAN CHECK VALIDATION
NAME - q q OTY. ELECTRIC PERMIT FEE
SOU PHONE A T -Q D
NOMERAcrons UTLETS-SWITCHES-RECEP 10.00/1.00
POL 1RG LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
PPLIANCES-RESIDENTIAL 4.00
10100 S, PHONEZ'TJ- PANELS 10.00 DATE OF APPLICATION
08CHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO,
ENGINEER
LIC,NO. SIGNS TRANS. 3.00 '
ADD Ess
SS SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP ITEMP.METER OR POLE INS. 20.00
ADDRESS TS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 C
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 Q �p 1
a u I hereby affirm llm[I am licensed under provisions of Chapter 9
ANCE DATE
(commencing with Section 7000)of Division 3 of the Business and 9U
BLDG. ELECT. PLG. MECH.
0 w i Professions Cole and t license is in full for a J effec e ❑ O ❑ ❑
o i m W Dae--l10_-
Class Cmn Number
m_ Dam 10 _t_g Contractor 4VRr tC.+
¢s IQc s a OWNER-BUILDER DECLARATON
BUILDING PERMIT
ow INFORMATION
gA
"
a 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u o ¢ ng reason.(Sec.]031.5,Business and Professions VALUATION $/FT.
Law for the following '
I- - PERMIT ISSUANCE 10.00
f � > f Code:Any city orcounly which requires a permit to construct,alter,
I[ ca ¢o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
G u requires the applicant for such permit to file a signed Statement that TOTAL
n w ce m he is licensed Pennant to the provisions of the Contractor's License PERMIT T
r z a
Law(Chapter 9(commencing with Section 700()of Division 3 ofthe
4 o Business and Professions Code)or that he is exempt therefrom and QTY, PLUMBING PERMIT FEE :
rc H $ the basis for the alleged exemption.Any violation of Section 7031.$ STORIES TYPE CONSTR.
e. by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dolan(5500).1:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
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 SO,FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees.provided o that such improve-
ments improvmennot tendedor withinroneyearoIf,however,thebuildingGAS-EA.SVSTEM-1INC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the ale d),r(of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30,00 RES IND CON PB Omer
O I asownerofthe tstructopertyhe project
0 0 ❑ ❑ D
licensed contractors: construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's i License Law does not apply
to contracts
owner of property who builds t r improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
the Cont for such projects with a contractor(s)licensed pursuant m
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.for this
reason WATER HEATER W/VENT 6.00
Owner Dale WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKHRS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I herehy affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3500,Lab.C.). 4
Policy NoHj,A AI O R Tll 8 RAO r`
0 0 CetliRe opyls hereby Tarnished. FIRESPRINK ENERGY T 24
Z Z R-.Certified col]y I fled with the city inspection division.
FO Applicim {oS](/}t/ MISC.- REFER TO ORD. Y[:] N0 YC] No
� N CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10,00 FLOOD ZONE A.L.U.C.
L 1 COMPENSATION INSURANCE PLG.CONTR. LIF NO. PLG.
a o (This section need not he completed if the permit is for one TOTAL Y❑ N V [] N
Z hundred dollars(S 100)or less.)
V 0 1 certify that in the performance of the work for which this per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,1 shall not employ any pi�rom in any manner so as to
O W become subject to the Workers'Compensation Laws of California.
C Date Applicant ALTER OR ADD TO 5.00 �' BUILDING
>- to NOTICE TO APPLICANT: If,after making this Certificate of Ex.
F Z emplion,you should become subject to the Workers'Compensation APPLIANCE5.00 FEE PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
U such provisions or this permit shall be deemed revoked AIR HANDLING U O 0/100 . .M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER .16.00 SEISMIC FEE
I hereby affirm that Ihere is a construction lending agency for EXHAUST HOOD 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM -
3097,CN.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
1 cerlily that 1 have real this application and stat,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 t0 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
above-mentioned property rfor epresentatives
ion purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL /J
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX%
may in any way accrue against s, aid City in consequence of the .PERMIT ISSUANCE H. _
TAX-
9 i f his p roof Vile-_t`�i�-_ MECH.CONT. LIG NO. MECH.
In 9- c' TOTAL TOTAL
Sgr neRuc of Apphcauticontraclor Unte - L-�j d Z PD Lyl l ESC f�^
OFFICE COPY