8937 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - U LL POINT PEN ONLY
• BU I LDING PROJECT I DEN TI TION _ PERMITNUMBER
BUILDINGAPPLICATION & P MIT
Aoos , O
BUILDING -ELECTRICAL-PLUMBI -MECHANICAL
�. 1 8937
Os PLAN CHECK VALIDATION
NAME �- QTY. ELECTRIC PERMIT FEE
PHONE
w No crows ` UTLElL_SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
f06ITR 'S ^ APPLIANCES- 4.00
DORE
AiQO^^D '
NE{{ 77 Rel PANELS' 10,00 PATE Of APPLICATION
ORRcurtfcT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
Llc.rvo. SIGNS TRANS. 3.00
ADDRESS ENG SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
AESS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 �(�
o
' 02 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 `6/dl l
a v U I hereby affirm that 1 am licenxtl under provisions of Chapter 9
ISSUANCE DATE
yA a, (commencing with Section 7000)of Division 3 of the Business and
¢ y BLDG. ELECT. PLG. MECH.
H h - Professions Co my livenL is N full fora• ciiarJ., O ❑ ❑
z o P, - license lass Lia Number V u[
¢ Y s ` a W BUILDING PERMIT
¢ ¢ OWNER-BUILI UfiCLARATI ON
K o v U MISC. REFER TO ORD INFORMATION
X
3 u H I hereby affirm that I am exempt from the Contractor's License
VALUATION E/fT.
H .. oa Law Code:Any cilylowing ounty whichequire.a perminess t tocndtruct.mons PERMIT ISSUANCE 10.00
frA>4 Code:Any city or county which requiresupermif foconstruchaltcq ELEC.CONTR. CO.INO.
¢ ¢ ¢ o improve,demolish,or repair any structure,prior fo its iszuancc,also ELEG.
DLL requires(lie applicant for such permit to file a signed statement that TOTAL PERMIT TO
K
he is licensed pursuant to the provisions of the Contractor's License
H z a Law(Chapter 9(commencing with Section 7000)of Division 3 of the PL8 �, 0( MLS]
Business and Professions Code)or that he is exempt therefrom and PLUMBING PERMIT FEE
¢ o the basis lot the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
d; � by any applicant for a permit subjects the applicant o a civil penalty ALTER-DRAIN -WATER (EA.) 6.00
of not more than five hundred dollars(5500t):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00OCC.GROUP RES.UNITS
their sole compensation,will do file 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
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 50.FT.FLDOF AREA TOTAL ACREAGE
himself re through his own employees,provided that such improve GAS-EA.SYSTEM-1 I N ETS 6.00
enfs are not intended or offered y sale.If,mpleveq the building
b 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 of sale.). V,
❑ I,as owner of the property,um exclusively contracting with INDUSTRIAL WAS E �30.00
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 1.00
contracts for such projects with a contractor(s)licensed pursuant to -SANITARYTORM EA200ft/1000
-S . .
the Contractors License Law. SEW ER30TRACT N0, PARCEL NO.
❑ I am exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 s� ACC.DATE ACC.FILE NO.
WORKFRS'COMPENSATION DECLARATION WATER TREATING EQUIP.,IL,,
5.00
I hereby affirm flat Ihave a certificate ol'cansean to self-insure. , ,y�,L ZONING ENG SITE NO.r
or a certificate of Workers'Compensation Imurancc,or a certified
copy thereof(Sec.3800,Lab.C.). LJ
Policy No. Company
0 ❑ Certified copy is hereby furnished. SPRINK ENERGY T$4
z 2 W Ce copy ed t th city int c tion divizion.
MISC. REP R T OR
O Appicxpl - Y ❑ NE] Y ❑ N�
jry CERTII'ICA'1'E OF F.XIiNI'TION FROM WORKERS' PERMI I $ NCE 10.00 Q ` FLOOD ZONE A.L.u.C.
LU Q COMPENSA19ON INSURANCE PLG.CONTR. O. TOTAL/S� V N� V N�
= Z (This cocoon need not be completed if the permit is for one
hundred dollars(4100)or less.)
U O 1 certify that in the performance of the work for which this per Q Y. MECHANICAL PERMIT FEE FEE SUMMARY
W H mit is issued,I shall not employ any person in any manner ol as t
U become subject to the Workers'Compensation Laws of California.
U.)
Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE'TO APPLICANT: If,after making this Certificate of Ex-
F. ? emptier,you,should bccomc subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply withFEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO i .) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is A construction lending agency for EXHAUST HOOD (WI ) `!,400
the performance of the work for which this permit is issued(Sec. - MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVE 0 1AI0, 0.50
Lender's Address ELECTRIC
( certify th,tl have read this applicmian and state that the above VENTILATION FAN (SINGLE) 4.00
i oration is correct.I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
rtdinunces and stoic lows rclming to building construction. and
'mmby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU(EEE FEE ECH. O MECHANICAL
abovomenlioned property for inspection purposes. U
(We) agree to save, indetnnify and keep harmless the City of MISC.- REFER TO ORD. 4>•
Cupertino against liabilities,judgments, :osis and expenses which CONST.TAX
Sy
in any way accrue ngai t said C in wnsequence of the PERMIT ISSUANCE 10.001/0
f got thi11 MECH.CONT. LIC.NO. MECH.
{\a XV7H DrnL s!o - TOTAL
MIgnature of Applicant/Contractor -Date /_
OFFICE COPY