9127 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATION PERMITNUMBER
Sun LDIN v yrs / APPLICATION & PERMIT 9127
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
/ OWNER' PLAN CHECK VALIDATION
�-L- NAME QTY. ELECTRIC PERMIT FEE f�(J f/J\Ow /.`
Q PHONE I IPL_,-' aces &-f,
CONT AC OR5 c(, u, i
NAME UTLETS-SWITCHES-RECEP 10.00/1.00 Posr X /n{�.� Is1iLl
LIC.NO. 3 LIGHTING FIXTURES 10.00/1.00 Sj.. rc 4.m14
CO
RAcrORs -
ADDRESS APPLIANCES-RESIDENTIAL 4.00
I re- L PHONE / PANELS 10.00 DATE OF A14 CATION
AORRCHITEC PANELS(OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
uc.No. SIGNS TRANS, 3.00
nooa'EOR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
zIPEMP. ER OR POLE INS. 20.00 ��
APPLICANT MO RS
ADDRESS SEE F E SCH.
SERVICE CHANGE 20.00 Ai0 1/-j
/8f�
w O o LICENSED CONTRACTORS DECLARATION 'TEMP.POLE 30.00 C
¢ v 1 hereb affirm that I am licensed under rovisions of Chv ter 9 s
Q y P P _ISSUANCE DATE
N<w (commencing*withSection 7000)of Division 3 of the Business and L L T. PLG. H.
H Professions Code nJ y license is in full fur n e ❑ ❑ ❑
O i w W License CWss Lic.Number ^I�
Dote Contractor 1�
H ~ J
03 w owmtR-Bulu3ER DECLARATION INFORMATIONIDING IT
we- � I hereby affirm that I am exempt from the Contractor's Liccnse MI REFER TO RD
u O ar Law for the following reason.(Sec.7031.5,Business and Professions . VALUATION S/FT.
H _ PERMI SSUA 10.00
w0 Code:Anycity orcounty which requires a permit to construct,alter,
2 aa Q improve,demolish,or repair any strGClum,prior to Its Issuance,also EL .CONTR. LI .NO. ELEC.
¢ requires the applicant for such permit to file a signed statement that TOTAL
dwm�` he Is licensed pursuant to the provisionso1lha Con tractor's License PERMITTO ov
F r Law(Chapter 9(commencing with Section 7000)of-Division 3 oflhe �a
io Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING IT FEE `-'/ku&7Q4-' O V 7 I
¢ I- �. the basis for the alleged exemption.Any violation of Section 7031.5 STORIES q� TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-D AIN&VENT-WATER IEA.) 5.00 ll
of not more than five hundred dollars($500).):
❑ 1,as owner of the property,or my employees with,wages as BACK FLOW PROTECT.DEVICE 4.00
OCC.GROUP REB.UNITS
sole compensation,will Jo 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 upply to an Owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00., 50.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 IEA) 200
builder will have the burden of proving that lie did not build or int- - , - . .
BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 RES IND CON Pe oro..
❑ I,as owner of the property,totin . .
n exclusively contracting with El ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sr,7044, Business LAWNSPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does suit apply
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 contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec..,BAP.C.for this WATER HEATER WIVENT 6.00
reason
Owner Date WATER SYSTEM 5,00 ACC.DATE ACC.FILE NO.
WORK Ii RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofconsant to sel0.inwre,
or a certificate of Workers Compensation Insurance,or a certified ZONING ENG,SITE NO.
-x copy there f Se 0,Lab.C.).
Policy N F c ompany - 1�R r
O ❑ Certifiedcnpy is hereby furnished. FIRE SPRINK ENERGYT24
❑ Certifl 1 co RIe w h cI y'ins eeY cion.
O Applicant �L•r� ice..._ X MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
~ rn / PERMIT ISSUANCE 10.00
Lu CIiRTI PIC OT PEN AX IOTI(1NER NCE RKb:RS' FLOOD ZONE A.L.U.C.
W � COMPENSATION INSURANCIi PLG:CONTR. LIC.No. PLG.
CL Z (This section need non be completed if the permit is for one TOTAL Y E] N❑ Y ❑ N❑
hundred dollars IS 100)or less.)
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
W U mit is issued,I shall not employ any person in any nanncr sO as to
O to become subject to the Workers'Compensation Laws of California.
y Date-Applicant ALTER OR ADD TO MECH. 5.00 BUILDING a
>_ W NOTICE: TO APPLICANT: If,after making this Certificate of Ex"
♦- Z 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 IOAOOC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the 3097 performance of the work For which this permit is issue)(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 ' MICROFILM
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• information n correct 1 agree to comply with all city anA county BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and snare laws relating to building construction, any
hereby authorize representatives of this city to enter upon the BOILER-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, casts andexpenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
gran n of this permit. /- MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Ignitlum of Applicant/Groci h 'lar Date
OFFICE COPY