09576 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER AD' APPLICATION & PERMIT
LDING
ADDRESS
Ess 2169') 197fMZl� MDCellan Rd. BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 09576
OWNER'S .., PLAN CHECK VALIDATION
Frank Luiz
NAME PHONE 252- 2 CITY. ELECTRIC PERMIT FEE
CONTRACTOR
NAME UTLETS-SWITCHES-RECEP 10.00/1.00
N
LIC.NQ2 4A52AA LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
ADDRESS ' APPLIANCES-RESIDENTIAL 4.00
CONTR
COMinerej;a St
PHON 739-0516
PANELS 10.00 DATE OF APPLICATION
ARLH TPANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.L.NO.
OR
ENGINEER
- sec.No. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH, x�
ADDRESS
SERVICE CHANGE 20,00
w o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 a
<U U I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. ME H.
P,
H i Professions CodyynnaannlJl�app��yy license is in full force >6 k ❑ O ❑
Z, o m - License Cly/zl[ZjrTi/con Number D CA,
° H ° Date_ 9�/y9QQ�-Contmnor_ BUILDING PERMIT
s w¢ OWNER-BUILDER DECLARATION INFORMATION
woA° MISC.- REFER TO ORD
S IL H I hereby collo that I am exempt from the Contractor's License VALUATION S/FT.
H u o j Law for the following rCason.(Sec.7031.5.Nosiness and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requiresa permit toconslrucq alter,
¢ Q 0 improve,demolish,or repair any structure,prior to its issuxna',also ELEC.CONTR. LIC.NO. ELEC.
w O u requires Ile applicant for a¢h permit❑1 lite a Sacred statement that _ TOTAL PERMIT T
n w$ he is licensed pursuant to the provisions of the Contractors License
HiQLaw(Chapter 9(commenciag with Section 7000)of Division 3 ofthe
4° Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢f $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
y Tom - by'any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
Of net more than five hlmdfed dollars(SS00).):
❑ I,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 Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5,00 SG.FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees,provided however,
such offered for that such
building GAS-EA.SVSTEM-l1NC.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 ire- RES IND LNG PB Omer
ProvC for purpose of sale.). INDUSTRIAL WASTE INTER. 30:00
❑ I,as owner Of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors m 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 IEA.) 1.00
contracts far such projects with a contrxetons)licensed pursuant to
the Contractor's License Law. SEWER-SAN TAR V-STORM EA.200ft/10.00 TRACT No. PARCEL NO.
❑ )run exempt under See. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACG FILE NO.
WORKERS'COMPF.NSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have o certdiCatC of consent to sClt�insum - ZONING ENG.SITE NO.
or a cpeerrt�tiif�qfic��aLt((eeg�oof Wo�[o�Brryykers'Compensation Insurance,or a cerlified
CopyPDI c7 "'�"-�r bmp b v) died Fac__
O } Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z Cr Certified�Wpy s filed ith the City inspection division. MISC.- REFER TO ORD.
O Applicant-B.L1$$-}iQat Y❑ N❑ Y ❑ N❑
F w PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
Ju CIiRTI FICCOI OP SAEIOTIPROM WORKERS'
UJ _ CUM not be completed
PLG.CONTR. LIC.NO. PLG. Y❑ N❑ Y ❑ N❑
d a (This union need not be completed if the permit is for one TOTAL
0 Z hundred dollars IS 100)or Tess.)
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT , FEE FEE SUMMARY
LL H mit is issued.I shall not employ any person in any manner so as to
Ubecome subject to the Workeri Compensation Laws of California
O w Date Applicant ALTER OR ADD TO MECH. 1 ' 5.00 BUILDING
} h NOTICE TO APPLICANT: If,after making this Certificate of Fx-
F Z emption,you should become subject to the Workers'Compensation APPLIANCE .15.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with - FEE
U such provisions or this PCnnit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the perl'nrmance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 a• MICROFILM
3097,Civ.C.). 1
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4,00
• ordina ordinances
is street. I s rel to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
oNinunms and state laws relating to building construction, and
heruhy authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above mentioned property I'or inspection purposes.
(We) agree to Save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which 0.00 CONST.TAX
may in any way accrue against said City in consegpence of the PERMIT ISSUA CE 10.00
grantin of this permit ME .CONT. r! C. MECH.
v i.. 11 TOTAL p pn TOTAL
Signature of Ap licanl/Conractor Ua[e Atlee Aea 3 4652 18.00
OFFICE COPY