9247 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LD1 NG PROJECT I DENTI FICATION PERMIT NUMBER
I BUILDING APPLICATION & PERMIT
ADDRESS
4� _ 9247
BUILDING — ELECTRICAL—PLUMBING—MECHANICAL
ER'S - PLAN CHECK VALIDATION
�[ N 7
• 1, oNEZ ,�I IOC ELECTRIC PERMIT FEE
NA.ERAcroRs OUTLETS-SWITCHES-RECEP 10.00/1.00
UC,No. LIGHTING FIXTURES 10.00/1.00
DDIR CTORs
APPLIANCES-RESIDENTIAL 4.00
ONTRA$
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECTon PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH.
E55 esa SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP ITEMP.METER OR POLE INS. 20.00 )
APPLI EMOTORS SEE FEE SCH.
ADDRESS
SS
SERVICE CHANGE 20.00 q���('�
o o LICENSED CON'I'RACI'OHS DECLARATION TEMP.POLE 30.00 // (J
a v u I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
. y2 (commencing with Section 7000)of Division 3 of the Business end
< °u BLDG. ELECT. PLG. MECH.
F O z Profusions Code,and my license is in lull force and effect. ❑ ❑ �; ❑
o z y,o License Chains—Lic.Number
Date Contranor
BUILDING PERMIT
a OWNER-BUILDER DECLARATION
aINFORMATION
se g LL I- I hereby affirm that I am exempt from the Contractor's License MISC.— REFER TO ORD
u0< Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
� - Code.Any city Nrcounty which nquinsa permit toconstruct,eller,
prove,demolish,or repair any structure,prior to its issuance,also ELEC.
G p jus ELEC.CONTR. LIC.NO.
DLL requires the applicant for such pminut to file u sighed Statement That TOTAL
n w PERMIT TO$m he is licensed pursuant to the provisions of the Contnelor's License _
tea, Law(Chapter 9(commencing with Section 7000)efDivision 3 of Ne
a PLB �
Business and Profe Blom Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
1 i o
H The basis for the alleged exemption.Any applicant
t tua cion 7031.5 STORIES TYPE CONSTR.
i ; _ by any applicant fora permit subjects the aRplicmrt toe civil penally
of not more than five hundred Dollars(55001.): ALTER-DRAIN&VENT-WATER (EA.) 5.00
0 1,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 Contractors License Law does not apply to an uwnef of
property who buflds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SG.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- ,
ments arc not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00 '
or improvement is sold within one year of completion,the owner. GAS-EASYSTEM-OVER 4 (EA.) 200
builder will have the burden of proving that he did not build or inn. . . .
. BUILDING USE
RES IND CON PR Other
prove to as o caner of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ L us owner m the property,the
exclusively contracting with REl El 0
licensed contractors to eContrathe project La 7044, Business LAWN SPRINKLERS-1 INC 5'V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The who
o License s th does not apply
to tr owner of property who builos tr improvesthereon.
poand who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a aontradorts)licensed pursuant to
the Contractor's License law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO, PARCEL NO.
❑ lamexemtun Sr Sec. .B.&P.C.for this WATER HEATER W/VENT 6.00
reason
_[ Owner_ q Date WATER SYSTEM
/- ACC.DATE ACC.FILE NO.
WORKE COMPENSATION DECLARATION WATER TREATING_q
I hereby affunn that 1 have a certificate of cmdaml m ulpin,um, -y ZONING ENG.SITE NO.
ora certificate of Worken'Compensation Insurance,or a certified
copy Ihercof(Sec.3800,Lah.C.). '
Policy No. Company
O Cl Certified copy is hereby furnished
FIRE SPR INK ENERGY TM
Z Z ❑ Certified copy is fled with the city inspection division.
on.
Applicant - RE ER TO RD. Y 'NY ❑ N�
CC W CE RT I FICATE OF Ii X EM PT ION FROM WORKERS' PE MIT ISSU — FLODDZONE A.L.u.C.
W COMPENSATION INSURANCE PLO.CONTR, i
CL 0 (This section need not be completed if the permit is for one TOTAL Y❑ NE] Y NE]
Z) Z hundred dullars($100)or less.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
UL U mit is issued,I shall not employ any person in any manner so as to
twcome subject to the Workers'Compenwtion Laws of California.
U d Dale Applicant BUILDING
} 0 NO'T'ICE TO APPLICANT: IL 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.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is o construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of The work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that l hlvercad thisapplication and slate that lheabove I VENTILATION FAN (SINGLE) 4.00
• information is correct. I agree to comply with all city and county PLUMBING Q
ordinances and slate laws refining to building construction, Oust BOILER-OONP(3 H.P.or 100,0008.T.U.) 6.00
hereby authorize repruunlulivn of this city U enter upon the BOILER-COMP (Oxer 100,000 BTU)SEE FEE SCR. MECHANICAL
above mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgrnenD, costs and expenses which' PERMIT ISSUANCE 70,00 CONST.TAX
m in an way crue aunt said City in consequence of the
Pis of Is 1. MECH.CONT. LIC.NO. MECH. '
/` TOTAL TOTAL
Si aRr lieant/Contracmr ate
OFFICE COPY