9228APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATI ON
APPLICATION &PERMIT
BUILDING - ELECTRICAL -PLUMBING -MECHANICAL
PERMIT NUMBER
9228
BUILDING
SS
OWN
NAME
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
PHONE
NAME °P5
UTLETS- SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
rka LIC. No.
co R afls'
AooHEss
APPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
PHONE
DATE OF APPLICATION
OR / RCHIC
ENGINEER
uc. No.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCHE OR ENG.
SPECIALCIRCUIT 5.00
PERMIT VALIDATION
rrEMP. METER OR POLE INS. 20.00
ZIP
ADDRESS PILOCANrs
AD°flE55
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
�I-,A's
LICENSED CONTRACTORS DECLARATION
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 lull force and of lest.
License Class Lic. NumberEl
ISSUANCE DATE
BLDG.
ELECT.
PLG. MECH.
= I
Date G CMllrator;4y
OWNER -BUILDER UIiCLARATIUN �
1 hereby affirm that I am exempt from the Contractor's
or's License
Law for the following reason. (Sec. 7031.5. Businessend Professions
Code: Any city or county which requires a permit to construct, alter,
BUILDING MIT
INFORMATION
REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
S/FT.
ELEC. CONTR. UC. NO.
TE ETC.
TOTAL
improve, demolish, or repair any structure, prior to its issuance, also
requires file aPpllcaut fOr Such permit HI file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
PERMIT TO
QTY. PLUMBING PERMIT FEE
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom unit
STORIES
TYPE ONSTH.
the basis For the alleged exemption. Any violation of Section 7031.$
I
by any applicant l'or a Permit subjects 0lc applicant to a civil Penalty
of not more than five hundred dollar, ($5001. )'.
ALTER -DRAIN -WATER (EA.) 5.00
❑ I, as owner of the property, or troy employees villi wages as
their sole compemutiun, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 4.00
OCC, GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA,CONO. 5.00
intended or offered for ,vale (Sec. 7044, BIISIOCSS and Professions
Code: The Contractor's License Law doe's not apply to an owner of
FIXTURES - PER TRAP .00
-
GAS -EA. SYSTEM- 11 NC. 4 O`CITLETS 6.00
property who builds or improve] thereon, and who does sonch work
himself or through his own employees, provided that such milirove-
mentsarenotintendedoroffered for sale. if, however, the building
SO. FT. FLOOR AREA
TOTAL ACREAGE
or improvement is sold within one year of co miction, the owner-
builder will have the burden of proving that he did not build or al-
prove 1, as owner ofthe.l.
C as owner of the property. and exclusively contracting with
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDING USE
RES INO ON PB Omer
❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
d the project (Sec, 7094, Business
, 704 ,
licensed contractors lu The
to Professions Code: The hbuildsContractor's License s til docs not apply
to an owner of property who builds improves thereon. mod who
LAWN SPRINKLERS -I INC 5 V.B. 6.00
LAWN SPRINKLERS -OVER 5 (EA.) 1.00
ASSESSOR RCEL NO.
lr
contracts fur such projects with a cool snorts) licensed Pursuant to
Pu
the Contractor's License Law.
C, -STORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
C1 am exempt under Sec.-, B.&P.C. for this
;;;!;SANITARY
R HEATER W/VENT 6.00
reason
Owner Date
For WATER SYSTEM 5.00
ACC. DATE
ACG FILE NO.
WATER TREATING EQUIP. 5.00
WORKHRS'COMPENSAI' ION DECLARAI ON'
1 hereby xlfirm that I have a certificate of consent t(,self-insure,
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof (Sec 3800, Tab .C.I
Policy NO. Cumpuny
FIRE SPRINK
Y E) NE
ENERGY 734
Y [] N�
Cetlil ted copy is herebyfnr015h
ertifsed co s filed, n he city inspection division.
1 vacant / /
MISC. - REFER TO ORD.
CF: R'I' IQ\T17 PTION PROM WORKERS'
PERMIT ISSUANCE 1, 4600
FLOOD ZONE
A.L.0 C.
COMM NSATIONINSURANCE
(This section need not be completed if the permit is for one
PLG.CONTR. LIG NQ
LG.
TOTAL
V� N�
Y� N�
hundred dollars IS 100) or leu.)
I certify that in the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner so as to
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to the Workers' Compensation Laws of Celifomia.
Date Applicant
ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICAN I': If, after making this Certificate of Ev
APPLIANCE 5.00
PLAN CHECK
FEE
emption, you should hecome subject In the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT (TO 10,000C.F.M.) 4.00
AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00
SEISMIC FEE
CONS'TRUCT'ION LI:NDING AGENCY
I hereby affirm that there is a construction lending agency I'or
EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued (See.
3097, Civ.C.).
MICROFILM
H EATING UN IT (TO 100,000 B.T.U.) 8.00
Lender's Name
Lcnduri Name x
HEATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
~
I certify that I have read this application and state that the above
inmrnoation is correct. I ogres to amply with all city and county
Ordinances and state laws relating In hudding construction, and
VENTILATION FAN (SINGLE) 4.00
PLUMBING
BOILER-COMP(3 H.P. or 100,0008.T.U.) 6.00
hereby authm-me representatives of this city to enter upon the
aboveanentlnned proPerry for inspection furpaus.
BOILER -COMP (Over 100,000BTUI SEE FEESCH.
MECHANICAL
_
(We) agree to save. indemnify ;cul keep harmless the City of
MISC. - REFER TO ORD.
Cupertino against liabilities, judgments, costs and expenses which
nice in any way accrue against said City in consequence of the
CONST. TAX
PERMIT ISSUANCE 10.00
granting, f this permit///s
MECH. CONT. LIC. NQ
MECH.
44 �-7_7-x-�
TOTAL
TOTAL
G
n
Sod l;,OIWA Leant CAddlra for Dale
INSPECTOR COPY