C9413 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
NG APPLICATION & PERMIT
ADDRESS X DDRE
r � ooRESSss
9
,401 a BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 9413
OWNER'S N HECK VALIDATION
NAME
n/J �T n
IWPOW,445ZGDDU DTV. ELECTRIC PERMIT FEE
NAMERAcroas r UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.N LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S +S�r-/J9 ANA 7� PPLIANCES-RESIDENTIAL 4.00
ADDRESS
YPHONE ' �S PANELS 10.66 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO:
ENGINEER
LIC,NO SIGNS TRANS. 3.00'
ARCH.
DD Ess ENC' SPECIAL CIRCUIT 5,00 PER�OMIJVTOON
ZIP EMP.METER OR POLE INS. 20.00 Iqq��ryry�j�~// o
ADDRESS MOTORS SEE FEE SCH. AUG 2 U 196y
ADDRESS
SERVICE CHANGE 20.00
Do LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 city of cuoertino
¢ so
a O I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
yz (commencing with Section 7000)of Division 3 of flue Business and
RE + LO ELECT. PLG, MECH.
F m Professions Code,and myyyy license is in full force and effect.
z o m License Clare[' Lie. ractor ❑ ❑ ❑
9 m F j Dated _Contractor
a m BUILDING PERMIT
¢ o i OWNER-BUILDER DECLARATION •' INFORMATION
w I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
VALUATION
F LL O 4 Law for the following reason.(Sec.7031.5,Businesand Professions PERMIT ISSUANCE 10.00
- -` Code:Any city orcounty whichrequiresupermif toconstrucLal ter,
¢ ¢ < 2 improve,demolish,or repair any strumtore,prior m its issuance,also ELEC.CONTR. „ LIG NQ ELEC.
O LL requires the applicant for such permit to file a signed statement that TOTAL ,PERMIT TO
w m he is licensed pursuant RI the provisions of the Contractor's License
Fzi Law(Chapter 9(conmmncing with Section 7000)of Division 3 of the
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ c the basis for the alleged exemption.Any violation of Secliou 7031.5 ST PE CONSTR.
by any applicant for a permit subjects the appllcuel tnucMl penalty ALTER-DRAIN&VENT-WATER MA.) 5.00
of not more Ilion five hundred dollop t$500).1:
❑ I,;is owner of the property,or my employee with wages us BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will no the work,and the st rueture Is not
intended or offered for sale (Sec. 7044, Busiiess and Professions DRAINS-FLOOR,ROOF,AR EA,CONDE 5.00
Code:9'he Contractors License Luw docs not apply m un owner of
property who build,01'Iltlprove5 thereon,:nld whO lines 611ch work FIXTURES-PER TRAP 5.00 50,FT,FLOOR AREA TOTAL ACREAGE
hinuclf or Through his own employees,provided Ilett such inlpmve.
..lcuts are not intended or offered for sale,ll',however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 8.00
or improvernent is sold within one year 01 conlplelion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving thin he did not build or int. BUILDIN USE
prove for purpose ofsale.)' INDUSTRIAL WASTE INTER30.00 RES IND PB Olney
❑ 1,as owner of the property,am exclusively contracting .with ❑ ❑ ❑ ❑ -
licensed cant rectors to consrvct the projctl(Sec. 7044, Resines LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSEs$o SPARCEL N0.
and Profesions Code: mThe Contractors License Law docs 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 wilh u conouons)licensed pursuant to SEWER-SAN V-STORM EA.200ft 10.
the Contractors License Law. / 00 TRACT ARY. PARCEL NO.
❑ I am exempt under Ser.-,It&P,C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COAI PENSATION DECLARATION WATER TREATING EQUIP. 5.00
I help by a(fir that I have a mrtlfma0..............to rel(-Insure' ZONING ENG.SITE N0.
or a cc t h etc W k omp,nvtion Insurance,o�Z�G u c�r/tificd
copy tl1�f( ,Lab.Cl v/J
Pore Y Pro"- Company
/` rod copy' he eby fur I
z 2 ❑ CetliHe ilCd th' C Aivisiom FIRE SPRINK ENERGY T-24
O Applicant MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
Mi:z w PERMIT ISSUANCE 10.00
EU - CERTI I° TEOPEX SA:IOTION FROM WORKERS' FLOOD ZONE A.L.u.c.
W > COMPIiNSA 'ION INSURANCIi PLG.CONTR. LIC.rv0. PLG.
Z IThis sectia_ 0on need not be completed il' the permit is for one TOTAL Y❑ N❑ Y❑ N❑
hundred dollars(S 100)or less.)
U O I certify that in the performance of the work for which this per. DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued, I shall not employ any person in any manner so as to
O E) become subject to the Workers'Compensation Laws of California.
Ca. Date-Applicant ALTER OR AOD TO MECH. 5.00 BUILDING S
>_ W NOTICE TO APPLICAN'1':.IL after making this Certificate of lis-
)..- ? emption,you should become subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK
provisions of (lie Labor Code, you ..mst forthwith comply with FEE
U such provisions or this permit shall be dmo
eeed rooked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction)ending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance 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
Lender's Address HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
infor"ation is correct. 1 agree to comply with all city and county PLUMBING
ordinances and stat, 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 In
offer upon the BOILER-COMP (OVer1OO,D00BTU)SEEFEESCH. MECHANICAL
ahuve-mentioned property for inspection purposes.
(We) agree to save, inde..mify and keep bunnies the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in an way accrue orainst 'lid in cunsequcncc of the
gmntin his )alit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
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Silo l u pplWlt/ n r Datoff
INSPECTOR COPY
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