C9407 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT J�o i
ADDRESS
Qr�#L BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
OWNER'S �, •�-�-�-5' PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
PHONE
c Rs
NAME UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
UC.NO. ILIGHTING FIXTURES 10.00/1.00
- c
ZAPS - APPLIANCES-RESIDENTIAL 4.00
ADDRESS
Z -fA PHONE PANELS 10.00 DATE OF APPLICATION
RCHIT T PLAN CHECK FEE D.C.NO
E .
OR PANS (OVER 200 AMP) 20.00
ENGINEER
uc.No. SIGNS TRANS. 3.00
ARCH
08 ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS �"• ZIP EMP. METER OR POLE INS. 20.00 ,r
APPLICANT'S 4 //
1 ADDRESS MOTORS SEE FEE SCH. 4 /``
1 SERVICE CHANGE 20.00 & [
�o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 �Q S'
u I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
°1 (commencing with Section 7000)of Division 3 al the Business and
¢ n B OG ELECT. PLC. MECH.
H m i Professions Code,and my license . in full force and effect. ❑ ❑ ❑
z o w - License Class Con Number
� m r �
Date-�l,�Con Nuctor
a a, % "/ BUILDING PERMIT
¢ w ¢ OWNIiR-BUILDER UECLARn'f10N INFORMATION
oAw MISC.- REFER TO ORD
F
S LL H 1 hereby affirm that I am exempt from the Contractors License VALUATION $/FT.
H .. 04 Law lir the following reason.(Sec.7031.5,Businessund Professions PERMIT ISSUANCE 10.00 -
Code:Any city or county which requirese pemtit to construct,alter,
2 �0 �/70
Q Q Q Improve,demolish,or repair any structure,prior to Its issuance.also ELEC CONTR. LIC.NO. ELEC. ((ff
O Ii requires the applicant for such permit to file a signed statement that TOTAL 3 1.7 PER TO
u w mhe is licensed pursuant to the provisions of the Contractor's License
FZQ
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
i O Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢ Fm the basis forthexl jo,d exemption.Any violation ofSection7031.5 RIES ' TYPE CON15111.
ate _ by any applicant fora permit subjects the applicant toe civil penalty ALTER-DRAIN -WATER IEA.15.00
of not more than five hundred dollars($5001.1'.
❑ I,as owner of the property or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
CodC The Contractor's License Law does not apply to an owner of
properly who builds Or improves thereon,and who does such work FIXTURES-PER TRAP S.BO SD.FT.FLOOR AREA TOTAL ACREAGE
•
mems are not intended or offered for sale.If,however,the budding GAS-EA.SYSTEM-11 NC.
himself or through his own employees,provided that such improve- 40UTLETS 6.00
or improvement is sold within one year of completion, - . .) 2.00 the owner- GAS EASYSTEM-OVER 4(EA
builder will have the burden of proving that he did not build or int- BUILDING USE
Prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 E IND CDN PB Other
❑ 1,as owner of the property,ant exclusively contracting with I ❑ ❑ 0
licensed contractors to construct the project(Sec.7044,Business -SPRINKLERS-1 INC 5 V.B. ' 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to au owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 _
contracts for such projects with a contractors)licensed pursuant to
theContrxctois License Law. SEWER;SANITARY STORM EA.200f[/10.00
. TRACT NO, PARCEL NO.
❑ Iwo exmnpt under Sec. ,B.&i'.C.lir this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK IiRs'Coh1PliNSA'DON DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure. ZONING
or a certificate of Workers Compensation Insurance,or a certified ENG.SITE NO.
copy Ihervof(Sec.3800,Lab.G.L
Policy No is m �142L-�
Q ❑ CerMted to yf ith Ld. city
FIRE SPRINK ENERGY T-24
z ❑ Certified n y is EIeJ v'Ih the ty inspection division. MISC.- REFER TO ORD.
_ Z r
O S+pplicallP ' V ❑ N❑ Y ❑ N❑
~ w CA'fE/ PERMIT'ISSUANCE 10.00 FLOOD ZONE A.L.0 c.
CC l �f R' OP I?%Eh1 PT UN PROM WORKIi RS'
LU „/ I COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG. y❑ N❑ V❑ NF]
Z[ This section need not be completed if the permit is for one TOTAL
hundred dollars(S 100)or less.)
0 O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any manner so as to
O become sc6ject to the Workcri Compensation Laws of California.
Do Ualc Applicant ALTER OR ADD TO MECH. 5.00 BUILDING /)
} rn NOTICE TO APPLICANT': If,after making this Certilo,de of Ex-
(_ Z empt ion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall he deemed revoked.. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby zfftno that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the Perlormanee of the work for which this permit is issued(See. MICROFILM
3097,Civ.C.). HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that l have read this application and state that the above VENTILATION'FAN (SINGLE) 4.00
• information is correct. I agree to comply with all city and county PLUMBING d
ordinances and state laws relating to building construction. and BOILER-ODMP(3 H.P.Or 100,000 B.T.U.) 6.00
hereby autlmriee representatives of this city to enter upon the BOILER-COMP lover 100,000 BTU)SEE FEE SCH. MECHANICAL
above-nientioned property forinspection purposes.
(we) agree 1n save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino a ainst liabilities,judgments, costs and expenses which CONST.TAX
may in,:yr se accrue against said City in conscyucnce of the PERMIT ISSUANCE 10.00
granting Of irpermi R-.e. t t CH.CONT. LIC.N0.x MECH. /a
TOTAL TOTAL
Sigm r pplican0/ or Datc
t INSPECTOR COPY