9412 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
162.60 S76 1_ zdr BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 9412
OWNER'5 PLAN CHECK VALIDATION
NAME
T1,x- /I _ QTY. ELECTRIC PERMIT FEE
. �/ U`ItF C PNONE M CC S
\ CONTRACTORS
rvA� UTLETS-SWITCHES-RECEP 10.00/1.00
- `� , 2C61A)eR- uc.NO. 3467.13 LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S
ADDRESS fes` - GU PE4Rnd �f / PPLIANCES-RESIDENTIAL 4.00
104 `/ D�. PHONE 4`(,-$'ISS PANELS 10.00 DATE OF APPLICATION
OgcwTECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
MVN�i LIG.No. SIGNS TRANS. 3.00
ADDRESSS ENG' k" SPECIALCIRCUIT 5.00 PERMIT VALIDATION
fi-q-0-44L ZIP TEMP.METER OR POLE INS. 20.00
none SSTS MOTORS SEE FEE SCH.
SMw1E AS COM}AAa.r"% SERVICE C.A. 20.00 pG EA_w
0 0 o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 p���1�
u v I hereby affirm that I am licensed under provisions of Chapter 9
w < w (commencing with Section 7000)of Division 3 of the Business and ISSUANCE DATE
r D i Professions Code,and my license is in full for 9p nd yffe i� BLDG. ELECT. PLG. MECH.
o z w o License C-�Ippss A Lic.Number-
[)are
umber�f 4 ti-� .p'1
FNH J [)are�'1'1-gy- Contractor I / ❑ 1�! ❑
ac
LE ¢ w ¢ OWNER-BUILDER DECLARATION BUILDING PE ITvAl-
o A
at a, INFORMATION, `
'st ; LL N I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
H LLo ¢ Law for the following reason.(Sec,7031.5,Business and ProfessionsPERMIT ISSUANCE VALUATION E/FT.
Code: e,dem y Dt Countypair any structure permit to construct,,also
at ¢ e0 0 improve,demolish,or repair any almefure,prior[o its issuance,also ELEC.CONTR. LIC.NO. ELEC.co // cF
LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
n w m he is licensed pursuant to the provisions of the Contractor's License
Fzi
Law(Chapter 9(conrmencing with Section 7000)o(Division 3 ofthe ELg•L7 VI-A,-
f 4 o Business anti Professions Code)or that he is exempt therefrom anti QTY. PLUMBING PERMIT FEE
K H$ the basis forthe alleged exemption.Any violation of Secrion7031.5 STORIES TYPE CONSTR.
A. 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(8500).): ✓
❑ 1,as owner o!the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCe.GROUP RES.uryrTs
their sole compensation,will do the work,and the structure is not
intended or offered lin,sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:Tire Contractors License Law does not apply to an owner of
Properly 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-
mentsarcnotintendcdorofferedforsale.If,however,the building GAS-EA,SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the comer-
builder
wnerbuilder will have the burden of proving that he did nor build or an. GAS-EA.SYSTEM-OVER 4 MA.) 2.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ 1,as owner of the propetly,am exclusively contracting with
licensed contractors lir construct the project(Sec. 7044,Business LAWN SPR I 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 SPRI ERS-OVER 5(EA.) 1.00
contracts for such projects with a contentious)licensed pursuant to
the Contractor's License Law. SEWER- ITA EA.200tt/10.00 TRACT NO, PARCEL NO,
❑ 1 ant exempt under Ser..,B.&P,C,for(h is WATER A ER / ENT 6.00
reason
Owner Date v WATERS T 5.00
f I 'IIU ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER NG QUIP. - .00 1
I hereby affirm that I have a certificate ofconsenr to self-insure, i
or a certificate of Workers'Compensation Insurance,or a certified -81 ZONING NO SITE NO.
copy t ereof(Sec_3 0 Lab.C.).
Policy NnQ}9�+}'1brrhpany-IA)GSF ifELA,(:N$u MIN
❑ Cerlified copy is hereby l'unrisbed. CO. FIRE SPRINK ENERGY T-7.4"
Z Z ❑ Cerl ified copy is Bled with the city inspection division.
H O Applicant IMISC.- REFER TO ORD. Y❑ " N❑ Y ❑ N[D
= LO CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE jaw , FLOOD ZONE A.L. C.
Lu
Q COMPENSATION INSURANCE PLG.CONTF. - LIC.NO. PLG. qq W
Z (This section need not be Completed if the permit is for one TOTA�p�. Y N Y❑ ry
U O
hundred fy that in the
)pe less)
I certify that h l n performance of ire work for which this per- QTY MECHANICAL PERMIT FEE _ FEE SUMMARY
(,(- Q mit is issued,1 shall not employ any person in any manner so as rn -,�
become subject to the Workers'Compensation Laws of California.
0 a Date Applmant ALTER OR ADD TO MECH. 5.001 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of lix-
F Z 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=C.F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=11F.M.) 6.00 SEISMIC FEE
I hereby affirm that thereis d construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
lire performance of the work !or which this permit is issued(See. MICROFILM
3097,Civ.C.). HEATING UNIT ITO 100,000 B.T.U.) 8.00
Lender's Name F"f^fE�
Lender's Address - HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC 3 y
3
I certify that I have read this upplicarion and state final the above VENTILATION FAN (SINGLE) 4.00
• , information n correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and safe laws relating to building all
city and co and
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH.
above-mentioned property for inspection purposes. MECHANICAL
(We) agree A.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 Said City in consequence of the PERMIT ISSUANCE 10.00
gr ing Df p iL MECH.CONT, - LIC.NO. MECH.
-Z•B� TOTAL TOTAL
Signal ofAppIjcAnUZNracror Date
OFFICE COPY