9364 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS ) 9360.
C�mf Q /�r BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
N 9/� PLAN CHECK VALIDATION
NAME // M� `X 12,11 // ((�r QTY. ELECTRIC PERMIT FEE
'4,
NAMERAcaoR$ /// L UfS UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO. LIGHTING FIXTURES 10.00/1.00
CONNTRACTORs PPLIANCES-RESIDENTIAL 4.00
ADESS
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARC"Ess ENG. SPECIALCIRCUIT 5,00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH. ///777
SERVICE CHANO,E 20.00 !JL k
o a i
Foo LICENSED COM1'TRACTQkS DECLARATION TEMP.POLE 30.00 /e1 6/f.S �
< v w I hereby affirm that I am licensed under provisions of Chapter 9 ISSUA/CEPDA'TE o
H Q (cmnmeneng with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLC. MECH.
r D z Professions Code,and my license is in full force and effect.
z o H - License Class Lic.Number
_ w DateContractor
R H
R, y f J
¢ � w a OWNER-BUILDER 111!CLARAT'I0N BUILDING PERMIT
w- o A U MISC.- REFER TO ORD INFORMATION
3 LL 1- 1 hereby affirm that I am exempt from lire Contractor's License vq LUATION
LL D j Law for the following reason.(Sec.7031.5.Businessand Professions
I- - g PERMIT ISSUANCE 10.Op //._.
Code:Any city or county which requires permit to const ruct.a Iter,
¢ asQ improve,demolish,or repair any structure,prior to its iswa ce,also ELEC.CONTR. LIC.NO, ELEC. QZ
a m LL requires the applicant for such permit to file a signed statement that TOTAL `-
u w he is licensed pursuant to the provisions of the Contractors License n PERMIT TO
Law(Chapter 9(cnmmencingwith Section 7000)ofDivision 3 of the
i o Business and Professions Code)or that he is exempt therefrom aWATV. PLUMBING PERMIT t FEE C-��
I a the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
d3 - by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars IS 500).1:
❑ 1,as owner of the properly,or my employees with wages as BACK FLOW PROTECT: DEVICE 4.00 OCC.GROUP RES.UNITS
tr
their sole compensation,will do the work,and the sucture is not
intended or offered for sale(Sec. 7044, Business and Pfofcasions DRAINS-FLOOR,ROOF,AR EA,GOND. 5.00
Code The Contractor's License Law does not apply to an owner of
property who builds Or improves thereon,and who does Such work FIXTURES-PER TRAP 5.00 BO.FT.FLOOR AREA TOTAL ACREAGE
himself or thrungh his own employees,provided that such improve.
mems are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or impmvcmcnl is,sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER30.00 RES IND CON PB Omer
.
❑ I,as owner of the property,am exclusively contracting with El ❑ El El 1:1licensed.contractors m construct the project ISee, 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code: I he Contractur'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 contraetons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
reClason I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
Owner ate WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK Ii RS'COMPI'NSATION DECI.ARATIO WATER TREATING EQUIP. 5.00
I hereby lbun that 1 have a certificate of consent to setGlnsure-
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG,SITE NO.
copy thereoffSec.3800,Lab.GJ. '
Policy Nn. Company
V ❑ Certified copy is hereby furnished.
Z Z ❑ Certified "my is Riled with the city inspeelion division FIRE SPRINK ENERGY T-24
op
♦- O Applicant MISC.- REFER TO ORD. Y❑ IN Y ❑ N❑
ti C1:R"I 11:1 CA'I'E OF EX 17 PTI ON Ir ROM WO k K Ii RS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C,
LU > COMPBNSAT'ION INSURANCE PLG.CONTR, LIC.NO. TPLOOTAL OTAL Y❑ IN E] V ❑ NE]
('Pcoa
his section aced not be spleted if the permit is for one
:3 Z hundred dollar,IS 100)or less.)
V O 1 rent, that in lire performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued, I shall not employ any person in:mv manner w as to
U become subject to the Workers Compensation Laws of California.
(L Dale Appbeant ALTER OR ADD TO MECH. 5.00 BUILDING
} rA NOTICE TO APPLICANT': If,after making this Certificate of Ex-
F Z emplion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
V 11101 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 I0=C.F.M.) 6.00 SEISMIC FEE
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. MICROFILM
3097,Civ C.1. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Leader's Address HEATING UNIT(OV ER 100,000 B.T.U.)9.50 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 coo fly PLUMBING
ordinances and stale laws relating to building construction, and BOILER-CDMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
habove ereby ncalioacd properly foriasp ofth i purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequenec of the
gran f this peon' MECH.CONT. LIC.NO. MECH.
TOTAL
,V
IgA re of TOTAL
p h n L mot
INSPECTOR COPY