9482 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS.
/ 114tIOW DING -ELECTRICAL-PLUMBING-MECHANICAL
9482
NAME S W� Ix PLAN CHECK VALIDATION
CITY. ELECTRIC PERMIT FEE
CONTRACTORS
v NAME 1, /' �l UTLETS-SWITCHES-RECEP 10.00/1.00
-/` L� 10•�d MM a /A CALIC.NO. Z75p✓ LIGHTING FIXTURES 10.00/1.00
I'X ADDRs
ADDRESS C
PPLIANCES-RESIDENTIAL 4.00
'Qa Aslvr✓L
PANELS 10.00 DATE OF APPLICATION
OARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
ua NO. SIGNS TRANS. 3.00
ADDDDR'ESS ENc. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT'S
ADDRESS MOTORS SEE FEE SCH.
Q 1
0 Utn�h A �f► I/T�/� SERVICE CHANGE 20.00
w w o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a u U I hereby affirm that I am licensed under provisions of Chapter 9
a w (commencing with Section 7000)of Division 3 of the Business and ELECT,ISSUANCE DATE
rn ¢„ BLDG. ELECT. PLG. MECH.
r o z Professions Cod• and my license is in full fur' B 4f v 1:1
❑ O
Zo z License C ass (f Lic.Number
M r ale Contractor
a m f
Ma w OWNER-BUILDER RBUILUIiR DCCLARATION BUILDING PERMIT
INFORMATION
w ;LL I- I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u_ o< Law for the following reason. 7031.5,Business and Professions VALUATION S/FT.
- ,, g PERMIT ISSUANCE. 10.00
Code Any city or county which requirese permit to construct,ager,
ca a p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
O IS requires the applicant for such permit to file a signed statement that TOTAL ^
w S he is licensed pursuant to the provisions of the Contractor's License PERMIT TOL
r z a Law(Chapter9(commencing with Section 7000)of Division 3 ofthe p {q-
4 0 Business and Professions Code)or that he is exempt therefrom and OTY. -PLUMBING PERMIT FEE
Q`1-$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
e. by any applicant for a permit subjects the applicant to a civil penalY / q R-DRAIN VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500).): 1
❑ I,as owner of the properly,or my employees with wages as MACK F LOW 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 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 IXTUR ES-PER TRAP 5.08 0
SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
meats are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
or improvement is sold within ane year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00
builder will have the burden of proving that he did not build or ire. BUILDING USE
prove for purpose of Sale.). INDUSTRIAL WASTE INTER. 3000 RES IND CDN PB ower
❑ I,as owner of the properly,am exclusively contracting with .
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS•1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:'rhe COntmctor s License Law does not apply
to an owner of property who builds or improves Hereon,and who LAWN SPRINKLERS-OVER 5( 0
contracts for such projects with a contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA, 0 f1/1 .00 TRACT NO. 'PARCEL NO.
❑ l am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT
reason SEP 1 n6 .if
Owner Date WATER SYSTEM 5A0 f_ ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARA'T'ION WATER TREATING EQUIP.
1 hereby affirm that I have a certificate ofcoasent to self-insure,
or a certificate of Workers'Compensation Ins5ranGe,or a certified ZONING ENG.SITE NO.
copy ther,�of1�es.3 0 Lab.C.).
policy
" pany�/ /G lNn
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T•24
Z 'Z 4 Gerllf opy is filed with city nspeclion division. v N Y N�
F O Applicant LJL/dam,/y/ MISC.• REFER TO ORD.
CC D CF.RTCFICATEOF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00/8- FLOOD ZONE A.L.U.C.
CLQ COMPENSATION INSU RA NCI: PL C NTR. y �s.`�MLIC.Ngo. PLG. IIs. (�1 ❑ ❑ ❑ ❑
fire sectldn need not be completed if the punnit Is for one �Q,J`' G TOTAL O C/ N Y N
U O hundred dollars(51001 or less.)
I certify that in the performance of the work for which this per CITY MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in any manner,as to
OW become subject to the Workers'Compensation Laws of California.
a. Omc Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NO'rICF.TO APPLICANT: If,after making this Certificate of Ex-
? emption,you should bacume subject to the Workers'Compensation APPLIANCE 5,00 PLAN CHECK
provisions of the Labor Code, you trial forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a 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.L HEATING UNIT(TO 100,600 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lenders Address ELECTRIC
I certify that 1 have read t1l5 application and ,are that IIIC above VENTILATION FAN (SINGLE) 4.00
inforamtion is correct. 1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and
BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 ---+
hereby authorize representatives this city to enter upon the 801 LER-COMP (Over 100,000 BTU)SEE FEE SCH. 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,judgments, costs and expenses whichCONST.TAX
in any way accrue a nst said City m cons quence of the PERMIT ISSUANCE 10.00
grant g of this permit MECH.CONT. - LIC.NO. MECH.
G TOTAL TOTAL
Si ure of Applicant/Contractor Date V
OFFICE COPY