9254 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT X254
X ADOREss BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
1 �a.n - W
OWNER'S PLAN CHECK VALIDATION
NAME G,.R.AA tz rl_0 QTY. ELECTRIC PERMIT FEE
H u PHONE
CONTRACTOR's NAME UTLETS-SWITCHES-RECEP 10.00/1.00
`xsec.rv0.
LIGHTING FIXTURES 10.00/1.00
r-oNTRACr tT ADDR Ess /�.,^^- �- PPLIANCES-RESIDENTIAL 4.00
{•,e,LI�,QJ�f.�
XPHory PANELS 10.00 DATE OF APPLICATION
A M Cr
OR PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIc.No, SIGNS TRANS. 3.00
AARCDDRESS ENG SPECIAL CIRCUIT $,(f0 PERMIT VALIDATION
I
ZIP TEMP.METER OR POLE INS. 20.00
ADDRESS MOTORS SEE FEE SCH, v a
ADDRESS
SERVICE CHANGE 20.00 /94a-
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a U U I hereby affimt that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
ry'i Date si!) Code,,and my license is in lull force and U
T tfl`y O ❑ ❑
Z O= - License Class Lie Namber
9 � H' Date, �sJt' Coni raclor
x s c BUILDING PERMIT
m wa OWNER-BUILDER DECLARATION INFORMATION
A OAea MISC.- REFER TO ORD
w u_ H I hereby al0rm that I am exempt from the Contractor's License VALUATION :i/FT.
H u o a Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alteror ,
K ¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
LL Rquires the applicant for such permit to file a signed acme nent WaL TOTAL PERMIT TO
e w m he is licensed pursuant to the provisions of the Contractor's License
s-
FZLaw(Chapter 9(commencing with Section 7000)of Division 3 ofthe
f 4 D Business and Professions Code)or that he is exempt therufrom and QTY. PLUMBING PERMIT FEE
I- a the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
dam by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) $.00
of not more than five hundred dollars(5500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code The Con lntclor's License Law does not apply to an uwmcr of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 60,FT.FLOOR AREA rorat ACREAGE
• mems are not
hde ownemployees,for sale.
If.hJ ever,hat such improve- GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00
mems are not intended or offered for sale.If.however,the building
or improvement is sold within one year of completion,the owner-' GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of prmving that he did not build or im- RES IND CON PB Omer
prove for purpose of sale,). INDUSTRIAL WASTE INTER. 30.00 E] El ElI ❑ 1,as owner of the property,am exclusively contracting with El 11
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and 1'rofessianu Code:The Cmllractor's License Law does nut apply
to an owner Of property who bunds or improves(hereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts'I'or such projects with a contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SAN ITARV-STORM EA.2001010.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sea .B.&P.C.far this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSA'IION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby clinic that I have a cerificalc o Fconsent to cicinsurc.
or a certificate of Workers'Compensation Insurance,or a certilied ZONING ENG.SITE NO.
copy thereof(Sec.3800.Lab.C.I
X Policy No. Company
❑ Certified Copy is Imreb)'tarot md. J FIRE SPRINK ENERGY T-24
Z Z !7 CertT co is fled 'th Ube city zpe ion division. MISC.- REFER TO ORD. f
p\ A*icanl v N v N
cc FtnPERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU CISR'I'IPICC0 OF EXEMPTION FROM WORKERS
W COMPENSATION INSURANCE PLG.CONTH. IJC,NO. PLG.
� This section need not be completed if the permit is for one TOTAL V❑ N� v N�
hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued. I shall not employ any person in any manner w as m
U become subject to the Workers'Compensation Laws of California.
d Date ApplicantALTER OR ADD TO MECH. 5.00 BUILDING
} rn NOTICE TO APPLICANT': If,after making this Certificate of Fs-
�. Z eniplum,You should become subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK
provisions o1' the Labor Code, you nest forthwith comply with FEE
U such provisions or this permit Shull be deemed revoked AIR HANDLING UNIT(TO 10,000 C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 1000C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the pern mumce 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 ELECTRIC
Lender's Address
n v
1 certify tum I hoveread this application and stain that tic above VENTILATION FAN (SINGLE) 4.00
information correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating In building construction, and BOILER-COMPI3 H.P.or 100,0008.T.U.) 6.00
hereby authori" 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, costs arm expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
granting of this perm[ MECH.CONT. LIC.NO. MECH.
Q. (1 n t.� / �-O-At TOTAL TOTAL
Sign r V^ a t raclor Dame
INSPECTOR COPY