9156APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTI FICA710N
APPLICATION & PERMIT
BUILDING - ELECTRICAL -PLUMBING -MECHANICAL
PERMIT NUMBER
-
9156
D
ADDREESSSS
Qae4
0iX40,
.WVS \g
NAME
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
r r
NAME T
OUTLETS - SWITCHES -RECEP 1 /1.00
LIGHTING FIXTURES 0/1.00 aftQ
CONTRA Rs
ADDRESS
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
PHONE if
DATE OF APPLICATION
IN zoj/%// y -��• A//
�/ % T
uc. No.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ADDRESS ENR.
SPECIAL CIRCUIT 5,00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00
ZIP
A
ADDDREORESSSS
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
l • _ -7v
LICENSIiU CONTRACTORS IJECLn RATION
TEMP. POLE 30.00
�
-�
1 hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect `
License Class -�_ Lia Number
Ualc t ' Con tractorQirl�hi
ISSUANCE DATE
BLDG.
❑
ELECT.
'PLG.
❑
MECH.
❑
BUILDING PERMIT
INFORMATION
P Tti'iG
(JWNIi R-IIUILUhR DECLA RA G
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason.(Sec. 7031.5, Busincseand Professions
Code: Any city or county which requires"a permit « r amstrucl, alter,
improve, demolish, or repair ally stmcture, prior to its issuance, also
requires the applicant for such permit to file a signed stalemenl that
he is licensed pursuant to the provisions of the Contractor's License
C
MISC. - `P'''REFER TO ORD
VALUATION
8/FT.
PERMIT ISSUANCE - O0 ],QUO
ELEC. CONTR. ,$ LIC. NO. ELEC.
n TOTAL , 0
_
PERMIT TO
Luw(Choptcr9(commcncing with Scnion 7000RM Division 3ot the
Business and Professions Code) or that he is exempt therefrom and
,/�
E(E(T UMBING PERMIT FEE
OTV. L
STORIES,I
TYPE CONSTR.
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant br'u pennit subjects thenpplicant to a civil penalty
of not more than fivcimndrrJ dollar, ( 8500).1:
ALTER -DRAIN -WATER (EA.) 5.00
❑ 1, as owner of Ore properly, or my employers with wages as
their sole com pen sat inn, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
o
RES. UNITS
z
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
intended' or offered for zine (Sea 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who docs such work
himself or through his own employees, provided that such improve-
menls2re.not intended or offered for sale. If, however, the building
/
F IXTURES - PER TRAP 5.00
50. FT. FLOOR AREA
/TOTAL ACREAGE
GAS - EA. SYSTEM -1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or int-
prose.for purpose, ofsale.).
❑ 'I, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDING USE ,
RES IND CO PB other
❑ ❑ ! ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: The Contractor's License Law dues not apply
to an owner of property who builds or improves thereon, and who
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
ASSESSO MRCEL NO.
t -
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contractsforsuchprojectswilhacontractraps) Iicesed pursuant to
the Contractor's License Law.
SEWER -SAN V -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
l um exempt .&
pt under Sec.-. for this
reason
/
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00!
' ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
W'ORKERS'COMPENSA'f10N DECLARATION
1 hereby affirm that I have a certificate of consent to self -insure.
or a certificate of Workers' Compensation Insurance, or a certified
r ZONING
ENG. SITE NO.
,.
copy thereof (Sec 3800, Lob.C.).
PoliclyicN,6-
llr
12 CerlileL ftfy urni5 ed.
Crti-• the cton division.
FIRE SPRINK
V ❑ N❑
ENERGY T"24
V ❑ N❑
MISC. - REFER TO ORD.
CB: RTIPIG\'1'E OP I' IiMP"PION Ii .I WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A.L.U. C.
PLG. CONTR. LIC. NO.
TOTAL
COMPIi . ATTON INS ANCIi
seatitin need not he completed if the pennit is for one
V ❑ N [:J
Y ❑ NE]
hundred doll o, ($100) or less.I
1 certify that in the pertimn:mce of the work for which this per-
noir is issued, I shall not employ oily person in any manner so as to
GTV MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to the Workers' Compensation Laws of California.
Dam Applicant
ALTER OR ADD TO MECH. 5.00
Nonni: TO APPLICANT It, afmr looking this Ceniticatc of lix-
enoptlon, yogehould hero.. subject l» 0m Workers'Compensulion
APPLIANCE 5.00
PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
such Provisions or this permit shall be deemed revoked.
FEE
AIR HANDLING UNIT (TO 10=C.F.M.) 4.00
AIR HANDLING UNIT (OVER 10=C.F.M.) 6.00
SEISMIC FEE
CONSTRUCTION 1.17ND1NG A09NCY
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.
3097. Civ.C.T
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's NamAdders
Lender's Address
HEATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
3
1 certify that I have read this application and stale that the above
VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county
ordinances and slate laws relating to building construction, and
hereby authorize mporAte lalives of this city to enter upon the
abovomenlioned property for inspection purposes.
PLUMBING
BOILER-COMP(3 H.P. or 100,0006.T.U.) 6.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
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 Doe
•o
CONST. TAX
PERMIT ISSUANCE 10.00
gran 'in thi,Perrial,
MECH. CONT. LIC. NO.
MECH.
TOTAL
TOTAL
Krat4ure lot p a D m
X INSPECTOR COPY
�x