9206 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
u
BUILDING PROJECT IDENTIFICATION PER NUMBER
aonDl G APPLICATION & PERMIT 9206
A p BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNERS PLAN CHECK VALIDATION
NAM QTY. ELECTRIC PERMIT FEE
PHONE
r Cc TRAC ITS
NA l OUTLETS-SWITCHES-RECEP 10.0011.00 I
uc.NO. LIGHTING FIXTURES 10.00/1.00
...
TRACTOR S? , X �I v) /Q 1
PPLIANCES-RESIDENTIAL 4.00
ADDRESS
RYWe p C/ppN Q PHONE
JPANELS 10.00 GATE OF APPLICATION
ARCHITECTPLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMPI 20.00
NGINEER
' uc.NO, SIGNS TRANS. 3.00 '
AARCH OR DDRESS ENG. SPECIAL CIRCUIT 6.06 - PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS -Q. QX
ADDR Ess (p2G MOTORS .SEE FEE SCH.
' `
yWFIRA CA QF 540 SERVICE CHANGE 20.00
an
o¢o. LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
<U U I hereby affvnt that I aa,licensed under provisions or Cllupler 9 _ ISSUANCE DATE
a w (commencing with Section 7000)of Division 3 of the Business and LD,. ELECT. PLG. MECH.
H H Professions Cod• a ty license is in full force d eff e.
Z o m icense s Lic.Number_ �{.}��.�,., q
9z ,:. Date-�Q= 45_Contructor_)N)L/9/.t2./L/^w'
BUILDING PERMIT 1
w _ OWNER-BUILDER DECLARATION INFORMATION
wop MISC.- REFER TO ORD
;w N I hereby affirm that I am exempt from the Contractor's License
u'0 j Law for the following mason.(Sec.7031.5,Business and Professions VALUATION $/FT.
H _ PERMIT ISSUANCE 10.00
i Code:Any city or county which requiresapermil to construct,alter, /q-5
Q Q Q 00.
Improve,demolish,Or repair any structure,prior to lis ISW issuance,also ELEC.CONTR. - LIC.NO. ELEC. (✓�f 1
a a LL requires the applicant for such permit to IIIe a signed statement that _ I TOTAL :PERMIT T
w m he is licensed pursuant to the provisions of the Contractor's.License
HiQ
Law(Chaptcr 9(commencing with Suction 7000)of Division 3 ofthe O
P i 0 Business and Professions Code)or that he is exempt Therefrom and OTY. PLUMBING PERMIT FEE yofw
X I-m the basis for the alleged exemption.Any violation of Section 7031.5 1 STORIES TYPE CONSTR.
ec byanyspilicant furapermil subjects the applicunl trial civil pmlally ALTER-DRAIN -WATER IEA.) 5.00
of not mom than five,hundred dollars(4500).): '
❑ 1,as owner of the property,or my employees with wages as BACK F LOW 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 owner of
property who builds or improves Ihercon,and who docs such work FIXTURES,,PER TRAP 5.00 50,FT,FLOOR AREA TOTAL ACR EAGE
himself ems re through his own employees,provided eve such im ilding ,
himself a through
inteugh his
oro(feted eeor sa provided
that sthemprovg GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose ofsale.). I INDUSTRIALWASTE INTER. 30.00 RES IND CON PB orae,
❑ 1,as owner of file property,am exclusively contracting with El o O E
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSo ARCEL NO.
and Nofessions Cache:'I'lie Conlmclnr's License law dues mol apply to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contrictorts)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
Oa Contracu.,s License Law. TRACT NO. PARCEL NO.
❑ I ion exempt under See. BAP.C.lin tills WATER HEATER W/VENT 6.00
re.Vm
Owner Dae WATER SYSTEM 5.00 ACC.GATE ACC.FILE NO,
WORKIiRS'COMI'RNSA'I'ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate ofconscnt to self.insum, ZONING
\' or a certificate of Workers'Compensation Insurance,car a certified ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
POIIA No.-Company-
0
o. Company Q ,TRY/Certified copy is hereby furnished. FIRE$PRINK ENERGY TY4
Z Z ifiopY is filed Nth 1 c ily 1 PecfsIm dlvlsion.
�{ a MISC.- REFER TO ORD.
O pPlicanl A`E� V❑• No V ❑ N�
~ ValPERMIT ISSUANCE 10.00
E P
CC - ERTIFICATH OF EXTION PROM WORKERS' FLOOD ZONE A.L.UO.
UJ COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG. V -] N v N�
0 (' permit
Phis section need not be completed if the Is for one TOTAL
hundred dollars IS 100)or less.) •
U O 1 certify that in the perfornlancu of IIIc work for which this Per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,1 shall not employ any person in any Ara Once so as to
OL) become subject to the Workers'Compensation Laws of California.
y Date Applicanl BUILDING ))�''••''��
>_ In NOTICE TO APPLICANT: H.after making this Certificate al'Ex- ALTER OR ADD TO MECH. 5.00 p V
I- Z emption,you should become subject to(he Workers'Compensation APPLIANCE 5.00 PLAN CHECK
pnrvslons of the Labor Code, you must forthwith comply will . FEE ✓f0.6 3
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO IOSMC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,060 C.EM.) 6.00 SEISMIC FEE r
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCTI 5.00
the performance of the work for which this permit is issued(Sue. MICROFILM
3097,Civ.C.L 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
1 certify that I have read this application and ,are Ilett the aboveVENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county BOILER-COMP H.P.Or 100,000 B.T.U.)'6.00 PLUMBING
ordinances and stale laws relating to building construction, and
hereby aulhoriee representatives of this city to eme, upon the BOILER-COM P,(3 Ove,io0,00o BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly for inspection purposes.
(We) agree Io save, indemnify and keep harmless file City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costsand expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
gr Iof tilis rmi' x A + MECH:CONT. LIC.NO.; TOTAL MECH.-
7(�
7-/a4TOTAL (03
/ nature ofA � I
g pp ant/Contnmlor Ua[c 3,
a - ,OFFICE COPY