9351 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATION
PERMIT NUMBER
BUILDING .APPLICATION & PERMIT � '
AO � S r BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 9351
Ow R'a Cj/ PLAN CHECK VALIDATION
//�_/(O QTY.
PHONE ELECTRIC PERMIT - FEE
NFMERACTOR OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO. LIGHTING FIXTURES 10.00/1.00
TRA
CONCTORS
ADDRESS APPLIANCES-RESIDENTIAL 4.00
C
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C,NO,
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ANDRESS ENG SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
zit EMP.METER OR POLE INS. 20.00
ASMOTORS SEE FEE SCH.
ADDREDDRESSS
SERVICE CHANGE 20.00 (,r
w o o LICENSEE,CONTRACTORS DECLARATION TEMP.POLE 30.00
a it U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
N < y (commencing with Section 7000)of Division 3 of the Business anti BLDG. ELECT. PLG. MECH.
H N z Professions Code,and my license is in full force and effect. 1:1 El
❑
Z i m License Class Lia Number
H Date Contractor
r W I BUILDING PERMIT
o fe U
OWNER-BUILDER UILDER DECLARATION r INFORMATION
wH I hereby affirm that 1 am exempt frn,n the Contractors License MISC.- REFER TO ORD
a 0 w P VALUATION $/FT.
r _o J Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
wN Code:Any city orcounty which requires a Permit to construct,alter,
QQQD improve, or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
w- DLL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License
z ¢ Law(Chapter 9(commencing with Section 7000)of Division 3 of the L8 �.
Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
r $ the basis for the alleged exemption.Any violation of$ection 7031.5 STORIES TYPE CONSTR,
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN (EA.15.00
of not more than live hundred dollars($5000.) t
0 I,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 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 •I
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedoroffered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
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 int- RES IND CON PB Omer
prove for purpose or ads.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of (lie property,um 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-OV ER 5(EA.) 1.00
contracts for such projects with a contractorts)licensed pursuant to SEWER•SANITAR V-STORM EA.200ft/70.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,BAP.C.for this WATER HEATER W/VENT 6.00
reason114- ��/�yy�.
Owner n.,. AYb - WATER SYSTEMAin5.00 ACC.DATE ACC.FILE N0.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. A 5.00
I hereby affirm that I have'a certificate ofconsent to self-insure, d ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified 'O
11 24 1
copy thereof(Sec.3800,Lab.C.). �+
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
ZZ ❑ Certified copy is fled with the city inspection division.
O Applicant MISC.- R ORD.
p: Y ❑ N❑ Y ❑ N❑
m PERMIT ISSUANCE .7.0,00
LU - CERT'II7CATli OPBXEMPTI PROM WORKERS' FLOOD ZONE a.L.U.C.
W > COMPENSATION INSURANCE
URANCE PLG.CONTR. LIC.NO. PLG.
CL 0 (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
:) Z hundred dollars CS 100)or less.)
U O 1 certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of Calilkmnia. BUILDING
y Date Applicant ALTER OR ADD TO MECH. 5.00
>_ m NOTICE, TO APPLICANT: If,after making this Certificate of Ex-
Z CntPtion,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 110MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MOCflM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the
pe3097.rformance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct.1 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
above-mentioned properly for inspection purposes. gO1LER•COMP (Own 100,000 BTU)SEE FEE SCH. MECHANICAL
(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
VMS any way accrue against said City in consequence of thegof thisL MECH.CONT. LIC.NO. MECH.
z�ET°TA` TOTAL
re of Applicant -ontrac r Date
OFFICE COPY
r 1
II a
BUILDING INSPECTOR'S OFFICE Bldg.Dept.
CITY OF CUPERTINO ff e�
E I --g—Backflow Device Sanitary Permit No. '
E � b Sewer Connection Plumbing Permit No. ,
� o
LL
9 Plumbing Final Lot No.
o r Owner or Tenant -
, s
° Traci I!/1
� m
N '
Date Connected "� a — 19 2rDate Final
-
PLUMBING INSPECTOR
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