9174APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY 11"165 7ka-
BU I LDING PROJECT IDENTIFICATION Fa
APPLICATION &PERMIT
BUILDING - ELECTRICAL -PLUMBING -MECHANICAL
PERMIT NUMBER
9174
Hot
AOR E55
ADDRESS
-!?,w
OW
NAME
OTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
PHONE
CONTRACTORS
NAME
NAME
UTLETS-SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
uc.No. 17
CONTRA
DRESCToga
ADDRESS
D
PPLIANCES- RESIDENTIAL 4.00
PANELS 10,00
-V PHONE
DATE OF APPLICATION
ARCHITECT
OR
ENGINEER
I .No.
PANELS (OVER 200 AMP) 2000
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ADDRESS ENG.
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 20.00
ASS
APPLICDDREA
MOTORS SEE FEE SCH.
SERVICECHANGE 20.00
( i
�
op
LICENSED CONTRACTORS DECLARATION
TEMP. POLE 30.00
1 hereby affirm that I am licensed under provisions of Chapter 9
ISSUANCE DATE
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full Bice and effect.
License Class (7 ,ju Lic. Number 1_1l1 7
Date 62._-, -2d Contractor
BLDG.
ELECT.
PLG. MECH.
BUILDING PERMIT
OWNER -BUILDER DECLARATION
I hereby affirm that 1 so exempt frons the Contractor's License
Law ns
CodA Any citylorcountng whiche]031S,ernut tocndtrut,altr,
Code', Any City or comely which structure priors to construct, also
improve, demolish, or repair any sticture, prior to its issuance, also
req is •s the applicant for such permit to file a signed actor' Li that
he pursuant to the of the Contractor's License
INFORMATION
M ISG.- REFER TO ORO
VALUATION
$/FT.
PERMIT ISSUANCE 10.00
ELEC. CONTR. LIC. NO.
TOTAL
TOTAL
ppq MlT TO
0C Ped
with Section
9 in mencingwith Shah an
.Lew (ess Dthenehm.vision 3
DA a�
O
dPrf"sier
is exem00) pt
Gold
Business d Professions Code) or that he is exempt therefrom and
QTY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
the basis to the alleged exemption. Any violation of Section 7031.5
byany lgrplic tforu permit subjects the applicant tnacivil penalty
of not more tlh five hundred dollars f85001J:
ALTER -DRAIN -WATER IEA.) 5.00
❑ 1, as owne of the property, or my employees with wages as
their sole cumpre ion, will do the work, and the structure is not
BACK F LOW PROTECT. DEV ICE 4.00
OCC. GROUP
RES, UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
intended or offered r sale (Sec. 7044, Business and Professions
Code: 'file Contractor. License Law docs not apply to an owner of
F IXTUR ES - PER TRAP 5.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
property who builds or I roves thereon, and who does such work
himself or through his own mployces, provided that such improve-
meisarenotintendedornt he building
GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improve ... cut is sold within the owner-
builder will have the burden obuild or im-
prove for purpose of sale.).INDUSTRIAL
❑ 1, as owner oI the propeacting with
GAS - EA. SYSTEM -OVER 4 (EA.) 2.00 �',
BUILDING USE
RES IND CON PB Omer
❑ ❑ ❑ ❑ ❑
WASTE INTER. 30.00 •�
licensed contractors to constr4, Business
and Professions Code. 'I'Ile Cons not apply
to an owner of property who n, and who
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
ASSESSORS PARCEL NO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts for such projects witpursuant to
the Contractors License Law.
SEWER -SAN V -STORM EA. 2001t/10.00
TRACT NO.
PARCEL NO.
❑ lain exempt under Sec.-\,vC.forthis
reason
WATER HEATER W/VENT 6.00
Owner Dune
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
WORM' RS'COMPENSA"PION DECLARATION
1 hereby affirm that 1 have a certificate ofemew.l m self -insure,
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof (Sec. 3800, Lab.0 h
Po icy Noompany 'u. ^ / •--/ T_ c
❑ Cer l leis copy is bcrcby urmshed.
�YCertificd copy is tiled with the city inspection division.
MTpTicutlX
FIRE SPRINK
V N
❑ ❑
ENERGY T"24
V N
❑ ❑
MISC.- REFER TO ORD.
CCRTIFICArE O_I' EXEMPTION FROAW'ORK'ERS'
PERMIT ISSUANCE 10.00
FLOODZONE
A.L.0.C.
PLG. CONTR. LIC. NO.PLG.
TOTAL 0,0
COhIPFMATION INSURANCE
(This section red not be completed if fila permit is for one
Y❑ N❑
Y❑ N❑
li dij d dollars IS 100) or le,I
1 cer hat m Utr pirfonnancs of the work for which this per-
mit is issued, not employ any person in any Tanner so as to
CITY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to the �ry��s Compensation Laws of California.
Date `"" ��
ALTER OR ADD TO MECH. 5.00
-App,
NO'1'ICIi '1 O AI'PLICAN'I': If, after ma this Certificate of Ex-
APPLIANCE 5.00
PLAN CHECK
emption, you should become subject to 1he�R i1*.us C' onlpera. ion
provisions of the Labor Code, you must Ii.nhavil, comply with
such provisions or this permit shall be deemed revoked.
FEE
AIR HANDLING UNIT (TO 10SMC.F.M.) 4.00
AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00
SEISMIC FEE
CONSTRUCT ION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
the 3091 C.), Le of the work for which INS permit is issued (Sec.
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATI NG UNIT (OVER 100,000 B.T.U.) 9.50
ELECTRIC
L`n`,sN
Lender's nddmss
I certify that I have read this application and state that the above
information is correct. 1 agree to comply with all city and county
ordinances and state laws relating to building construction, and
VENTILATION FAN (SINGLE) 4.00
PLUMBING
-
BOILER- H.P.or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
abovc-mmntioned papery for inspection purposes.
MISC. - REFER TO ORD.
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue against said City in Consequence of the
CONST. TAX
PERMIT ISSUANCE 10.00
grantingof this permit.
MECH. CONT. LIC. NO.
MECH.
TOTAL
TOTAL
Sig uturu ppll and ontador Date
INSPECTOR COPY