9194 (2) �PLICANI TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI UDI NG PROJECT 1 DENTI FICA - 'PERMIT NUMBER
noon ss APPLICATION & PEOT
810 5�` CM3Eh` j�� BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 9194
OWNER'S PLAN CHECK VALIDATION
unME o - T ELECTRIC PERMIT FEE
I T- PHONE
NAMERncroRs UTLETS-SWITCHES-AECEP TMIXI/1.00
E&CX1Y1CV-4 GWC_W1("L,c.NO. "y/519 / b LIGHTING FIXTURES Ao00/1.00
ADDRESS Rs PPLIANCES-RESIDENTIAL 4.00
Z3'7 S MORAISO4oPHONE -2%6-J9690 PANELS 10.00 DATE OF APPLICATION
ARRCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P,C.NO.
O
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
AARCHOR DDRESS ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. 20.00
ADDRESMOTORS SEE FEE SCH. 10
ADDRESS
/
SERVICE CHANGE 20.00
wo PAI
o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
< uw I hereby affirm that 1 am licensed under provisions of Chapter 9 a ISSUANCE DATE
H¢ N (,.......facing with Section 7000)of Division 3 of the Business and �8LOG. ELECT. PLG. MECH.
F n Z Professions Code.,find my license is in full force ypd fff r adQ ❑ ❑ ❑
Z o.m- Liccnsc Class I O Lic.Nwnber I / / p p
9 y F Date 4-2 Comructor EKY 1 C 1�� / YI Ef U6
¢ a ¢ OWNER-BUILDER DECLARATION BUILDING'PERMIT,'"'
. o a u _ INFORMATION
X ; 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.(Sec.7031.5,Business and Professions VALUATION $/FT.
_ PERMIT ISSUANCE .30A0 C a
fto Code:Any city county any structurep Prior
tto o its
"
a K Q O improve,demolish,or repair any structure,prior to its Issuance,also ELEC.CONTE. LIC.NO. ELEC. (/-v
wLI ¢ requires the applicant for such permit to file a signed sunement that TOTAL PERMIT TO
$w he is licensed pursuant to the provisions of the Contractor's License
F z Law(Chapter 9(commencing with Section 7000).&Division 3 oflhe
rt _ G
P Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE' L� '
SC F D 0the basis for the alleged exemption,Any violation of Section 7031.5 STORIES TYPE CONSTR.
d ; _ by any applicant fora permit subjects the applicant toeCivil penalty Al-TER-DRAIN 5.00 /AQ
of not more than five hundred dollars(my em): W
O 1,as owner of the property,or my employees with re is not
BACK FLOW PROTECT. DEVICE -4.00
Her sole compensation,will Ao 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 docs such work FIXTURES,PER TRAP 5.00 50,FT.FLOOR AREA TOTAL ACREAGE
himself m through his own employees,provided that such improve- /
mentsare through
ot or employee sale.If,Id film such
building GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.QQ ,ILDING USE
builder will have rite burden of proving that he did not build or im- RES O CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ - ❑ ❑
licensed contractors to Construct the project(Sec.7044,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law docs nal amply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed Pursuant In SEWER-SANITARY-STORM EA.200ft/10.00
lire Contractors License Law. TRACT NO. PARCEL NO.
❑ I all)exempt under Sec. ,B. .P.C.for If is WATER HEATER W/VENT 6.00
reason
Owner Dale WATER SYSTEM 5,00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insurr.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO,
copy thereof(See.3800,Lah.C.)- -
Policy No. Company -
O ❑ Certified copy is hereby furnished. FIRESPRINK ENERGY T-24
Z Z ❑ Certified copy is tiled with the city inspection division.
Q Applictunt MISC.- REFER TO ORD. Y ❑ N❑ ❑ ❑
V N li
= T CERTIFICATEOF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.001 FLOOOZONE A.L.U.C.
LU COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG,
G- O (Phis section need not be Completed if the permit is for one TOTAL Y❑ N❑ Y EJNEI
=) Z hundred dollars IS 100)or less.)
L) O 1 Certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mil is issued,I shall not employ any person in any manner so as to
U become suJ��I tp rise Workers' o ..salla sou fornix.
ED
Our nk "-P�CApplicant -L -I ALTER OR ADD TO MECH. 5.00 BUILDING
} y NO"&ICE 1'0 APPLICANT: If,erre making lhrs Cerlil'icule of lix-
F Z emption,you should become subject In the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply will! FEE
U such provisions or this permit shall be deemed revoked. 000C.AIR HANDLING UNIT(TO 10, F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10P00QflM.) 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.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lenders Address ELECTRIC
I certify 11,411 have read this application and stale that the ahavC VENTILATION FAN (SINGLE) 4,00
information n coater. I agree to Comply with all net and county BOILER-COMP(3 H.P,or 100,000 B.T.U.) 6.00 PLUMBING
iordinancesnformation
and stale laws relating m building construction, and
hereby authorize representatives of
ec this purposes.s city to entre upon the
above-mentioned property
forinspection BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
y hi
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against Said City in consequence of the
anon of this permit MECH.CONT. LIC.NO. MECH. -
c-s 6-21-8 TOTALMECH, TOTAL
g re ol'Ap nth/Contractor Defe
OFFICE COPY