9344 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON - PERMIT NUMBER
BUILDING APPLICATION & PERMIT
-� ADDRESS
,36 &7 �, F BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 9344
OWNER'S `ISI r E
' PLAN CHECK VALIDATION
x� rvamE nLV QE /960. Y• '' a x'; ELECTRIC;PERMIT " " 'FEE=AUSTIE , -
NAME AOTORs �((/'�1 DF OUTLETS-SWITCHES-RECEP 10.00/1.00 lr� J
l�"p,bT0.) a�(L'Pas a..... LIGHTING FIXTURES 10.00/1.00 V^ 7
CON
ADDRESSrRacTDRs' APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
RRGHfTscT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
O
ENGINEERn'D,
LIC,NO. SIGNS TRANS. 3.00 ry
ARCH,OR ENG. - PERMIT VALI ION
ADDRESS SPECIALCIRCUIT 5.00
ZIP EMP.METER OR POLE INS. 20.00
AOOR as
a ��'
AMOTORS - SEE FEE SCH. Jv �♦\0
OR � -
SERVICE CHANGE 20.00
w o o 'LICENSED CONTRACTORS DECLARATION TEMP.POLE 0.00
a i u I hereby affirm tliat 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
w ¢a (commencing with Section 7000)of Division 3 of the Business and B G. ELECT. -PLG. MECH.
F o i Professions Cade,and my license is in full force and effect. 73
0(°., - License Class
z z _ G Lie.Nomber
0 I- w Datc Contractor ❑ El O
F -
5 x ¢ - OWNER-BUILDER DECLARATION ! '7`BUILDINO`PERMIT: ,e R z
`x ;LL I- 1 hereby al'I'irin that I am exempt from the Contraclor's'License MISC.- REFER TO ORD `'iIN FORMATION$/.x s"
FUDe Law for the following reason. 7031.5,Business and Professions PERMIT ISSUANCE VALUATION $/FT.
� w0 Code:Any city or county which requires a permit to construct,alter,
10.00 Oi
¢ va ¢ , improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
iL G Q requires the applicant for such permit to file a signed statement that TOTAL
u w m°' he is licensed pursuant to the fraEMIT TO
p provisions of the Contractor's License
r z i Law(Chapterand
Professions
C d comm Section is 00)exempt
therefrom flic
and -- °
E 4 o Business and he alleged exemption,
or that he Is exempt therefrom and QTY. PLUMBING PERMIT - - ` TEE
B: r$ by basis for the alleged exemption.Any violation of Section malty STORIES TYPE CONSTR.
a3 by any applicant fora permit subjects $500).applicant toacivil penalty ALTER-DRAIN -WATER (EA.) 5.00
' of not more than five hundred dollars(8500).):
❑ 1,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 Bad Pi-ot'essions DRAINS-FLOOR,ROOF,AR EA,CON D. 5.00
Code:The Contractor's License Law does not apply to an owner of
• properly who buildsis improves thereon,and who does such work FIXTURES-PER TRAP 5,00 s0.FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees,provided that such improve-
oments rimprovemenotnntendedwithinoffered
oneyeaale.If,mpletion the the owing GAS-EA.SVSTEM-l1NC.40UTLETS 6.00
or improvement is sold within one year of completion,o t the owner-
builder will have the burden of proving that he did not build or int- IGAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
prove 1,as ownerose
ofsale.).p E IND CON PB Omar
❑ I,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00
❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 7K
❑ASSESSOR❑S PARCEL❑NO.
and n owner of property
The Contractors License s th does oat apply
to tr owner of property who builds t r improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a eontruetor(s)licensed pursuant to
the Contractor's License Law. � SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt Ondr ,B.&P.C.for this WATER HEATER W/VENT 6.00
eason
Owner Date - WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby 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 thereoffSec.3800,Lab.CJ.
Policy No. Company .,
Q ❑ Cetlified copy is hereby famished. FIRE SPRINK ENERGY T-Z4
Z Z ❑ Certitied copy is filed with the city inspection division. ❑
FO Appliexnl MISC.- REFER TO ORD. Y NE] YE] N❑
W CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
UJ > COMPENSATION INSURANCE PLO.CONTR. - LIC.NO. PLG.
O_ Z (This section need not be completed if the permit is for one TOTAL Y[:]: N❑ Y E] NEI
hundred dollars(8100)or less.)
U O I certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMAFiV
LL U mit is issued,I shall not employ any person in any manner so as to - - -
become subject to the Workers'Compensation Laws of California.
BE Date Applicant BUILDING
>_ 0NOTICE TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
F ? 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=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.EM.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) -5.00
the performance of Hurwork for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 6.00
Lender's Name
Lender's Address HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
I certify that l have read this application and stale 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 to building construction, and BOILER-COME(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives ec this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned prepresentorinsp of
purposes.
(We) agree to'snve, indemnify and keep harmless the City of MISC.- REFER TOORD.
Cupertino against liabilities,judgments, costs and expenses which CONST..TAX
may in any way a gar st said ity in consequence of the PERMIT ISSUANCE 10.00
grand Of is I. MECH.CONT. LIC.NO. MECH.
\� TorAL TOTAL
J� Signa e.1 Applicant/Contractor Date a,
OFFICE COPY -