C9426 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT IDENTIFICATION PERMIT NUMBER ,e
7BUILDING APPLICATION & PERMIT ��n 9426 /(i"
ADDREss 9 'bm�j Five
� , U
T BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
1 DWNER'$ PLAN CHECK VALIDATION'
NAME _
• / ' `0I ELECTRIC PERMIT FEE
V`A, IM1e` .l PHONE
/ CONTRACTOR y1 UTLETS-SWITCHES-RECEP 10.00/1.00 LP V
Cor)j kC.No. 2q LIGHTING FIXTURES 10.00/1.00
noo ess TORS PPLIANCES-RESIDENTIAL 4.00
1r JC r ,PHONE '733-1136,11PANELS 10.00 DATE OF APPLICATION
OR
PANELS (OVER 200 AMP) 2000 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO SIGNS TRANS. 3.00
noo Ess eNa. SPECIALCIRCUIT 5,00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
ADDRESS rs MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 �Lw�
° TEMP.POLE 30.00
0 L/L
F O o LICENSED CONTRACTORS DECLARATION / S
a C,U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
i (commencin with Section]000)of Division 3 of the Business and
< m g BLDG. ELECT. PLG. MECH.
r y z Professions Code,and my license is in fill.farce and effect ❑ O ❑ ❑
z 0 m -' License Class I.ic.Number
F z to Uate��CotRractor
a BUILDING PERMIT
0 i
OWNER-BU
DECLARAT INFORMATION
w ; a- � 1 hereby affirm that I am exempt from the Contractors License MISC.- REFER TO ORB
a -
r• �. o j Law for the following reason.(Sec.7031.5,Business and I'rol' mVALUATION $/FT.
essns PERMIT ISSUANCE 10.00 dk
Code:Any city or county whichrequiresapermittoconstructulter, q 00
Ii < 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTH. LIC.N0. ELEC.
o ¢ rcqulres the applicant for such permit to file a signed statement that TOTAL y,[.
R
mhe is licensed pursuant to the provisions of the Contractor's License lw_ PERMIT TO
Fz >
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE ���/ 7i 4
f Z 0
¢ H $ the basis for the alleged exemption.Any violation ofSection 7031.5 STORIES TYPE CONSTR.
a ; by any applicant for a permit subjects the applicant tea civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(8500).):
❑ I,as owner of the property,or my employees with wagesas BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sola compensation,will do the work,and the Ion"ore is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractors License Law does not apply to an owner of
property who builds of improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees.provided that such innprove-
ments a re not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 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 im_ BUILDING USE
prove for puppusc 0f sale.). INDUSTRIAL WASTE INTER3000 RES IND CON PB other
❑ 1,as owner of the property,am exclusively compacting with . .
11 ❑ El ❑ ❑
licensed contractor, 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 contractor(s)licensed pursuant to SEWER-SAN V-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ l am exempt under Sec. ,B,&P.C.for this WATER HEATER W/VENT 6.00
rcas0n
owner Date WATER SYSTEM 5.00 ACC.DATE ACC,FILE NO.
WORKHRS'COMPHNSA'FION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance or a certified
copy thereof(Sec.3800.Lab.C).
Policy No. Company
Q ❑ Cerlil,al Copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z 2 ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.O'C Applicant Y As Y ❑ N�
~ PTIONOF PERMIT ISSUANCE 10.00
CIiRTI PICATIi li%Ch1 FROM WO RS' FLOOD ZONE A.L.U.C.
IL > COMPCN&ATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL Z This section need not be completed if the permit is for one TOTAL Y N� Y N0
hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work I'or which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
.,ALL mit is issued,I shall not employ any person in any inanocrso as to
become subjuy-1 to�tlm Workers pensalionU fCBI" it
Date_eii" A I' . i BUILDING
O y NOTICC1l YY6'CI'h A,Pfi,: IC a cr n t g( i ,x_ ALTER OR ADD TO MECH. 5.00 U Sa
F. ? eruption,you should become subject t th epi Gnnp!nsation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
CJ 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 10,000C.F.M.) 6.00 SEISMIC FEE
I hereby al'I'irm thin (hare is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
Oic performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.CTL HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)8.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• information is correct, 1 agree to comply with all city and county PLUMBING
ordinances and stale laws relating to building construction, and BOILER-OOMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP(Over 100,000 BTW SEE FEE BCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments; costs mid expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
gra ling fthis porn... MECH.CONT. LIG NO. MECH.
6N,327 J - TOTAL TOTAL /p29
/�/ Sig at o so- i i ra r Dat
INSPECTOR COPY
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