C9310 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING �1 APPLICATION & PERMIT
ADDRESS
n itBUILDING - ELECTRICAL-PLUMBING-MECHANICAL 9310
OWNS 5 PLAN CHECK VALIDATION
NAME OTY, ELECTRIC PERMIT FEE /�
' PHONE /lo V
c ACTR UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
LIC.NO. LIGHTING FIXTURES 10.00/1.00 r vL
CONTRACTOR'S APPLIANCES
4.00 ] S /'/�`;
ADDRESS '
A PHONEPANELS 10,00 / DATE OF APPLICATION
AH C H IT 40- PLAN CHECK FEE P.C.NO.
OR GINEEfl,rtt1ENGraN�e PANELS (OVER 200 AMPI 20.00
LIG.No 7 SIGNS TRANS. 3.00
ADDRESS ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESI ZI EMP.METER OR POLE INS. 20.00
AS"T MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
o a LICENSED CONTRACTORS DECLA r TION TEMP.POLE 30.00
a v u I herchy affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
Z (,mnnun,uhg with$,,lion 7000)of DivDion 3 of the R.,in,Bs andBLD - ELECT. PLG. MECH.
F n z Professions Code,and by license is in full forty and effect.
z o m - License Class Lia Number
Q w r w Date Contractor
a x f a BUILDING PERMIT
¢ ¢ w u OWNhR-BUILDER DECLARATION INFORMATION
F
;LL y 1 hereby affirm shot 1 am exevhpt from the Contractor's License MISC.- REFER TO ORD
LLLLo J Law for the following reason(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
F - Code'.Any city or county which requires a permit to construct,alloq h
• aF ¢ ¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTH. LIC.NO. ELEC.
to - D 2 requires the applicant for such permit to file a signed statement that TOTAL .'e' E MIT TO
A w m LL he is licensed pursuant to the provisions of the Contractor's LicenseLit f
Uzi
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe /.
a Business and Professions Code)or tlwt he is exempt therefrom and CITY. PLUMBING PERMIT FEE 41,17
r o the basis for the alleged exemption.Any violation of Section 7031.5La
$TO E P C $TR,
by any applicant for a pennit subjects the applicant toacivil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred Dollars(S500f):
❑ I,as owner of tire property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP ' RES.UNITS
their sole compensation,will do tire work,and the structure is nut
intended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:'fire Contractor's License Law docs not apply m un owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT,FLOOR AREA TOTAL ACREAGE
himself Or through his own employe,,,provided that such improve-
mentare not imendedoroffered for sale.If.however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one 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 Hit- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RE IND CON PB Other
❑ 1,as owner of the proluerty,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:The Contractor's License Law does not 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 contmmons)licensed pursuant to SEWER-SANITARY-STORM EA.200ft 10.00
Ne 9, tractor S License Law. / TRACT NO. PARCEL NO.
.S[J I nm exempt under Sec. ,B..Y I'.C.for this WATER HEATER W/VENT 6.00
ro
Owner w Date/ WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
N RKERS'COMPENSA'T ION DECLARATIO. WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate o(cousenl to self-insure, ZONING ENG.SITE NO.
aV or a certificate of Workers Compensation Insurance,or u certified
copy th,mof(S,c.3800,Lab.C.).
Policy No, Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z O Certified copy is'filed with the city inspection division. MISC- REFER TO ORD.
O Applicant _ Y❑ N❑ Y ❑ N❑
cc: W CERTIFICAT Ii OIr EXEMPTION FROM WORKERSPERMIT ISSUANCE 10.007 FLOOD ZONE A.L.U.C.
LU 1 COMI'F.N$ATION INSURANCE PLG.CONTR. LIC.NO. PLG. /- e, Y❑ N❑ Y El , N❑
CL Z (this section need not be completed if the permit is for one TOTAL
hundred dollars(S 100)or lessA
U O I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mit is issued, I shall not employ any person in any manner so as to 4
U Qbicmne subject to the Workers'Compensation Laws of California.
O- Dma ApplicantALTER OR ADD TO MECH. 5.00 BUILDING ee
},vw NOTICE'1'0 APPLICAN"T'. If,after making this Cerlificate of lix-
F-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
U such provisions or this pernhit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 4.00 FEE
' 'CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 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.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC /
• I certily that I have read this application and slat,thus the above VENTILATION FAN (SINGLE) 4.00
infonnalion is correct. I agree to conhply with all city rout Lou', PLUMBING
ordinances and slate laws relating to building co..traction. and BOILER-COM (3 H.P.or 100,000 B:T_U.) 6.00
hereby euthorire representatives of this city o enter upon the BOILER-COMP IOwn 100,000 BTU)SEEFEE SCH. MECHANICAL
above-nmnttaned property for mepection Purposes(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX /
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
granting u is Pcrn v MECH.CONT. LIC.NO. MECH. /
TOTAL / TOTAL
of Ap n OnIQ esq� III [or v
' - INSPECTOR COPY
s 1
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