09624 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBERAPPLICATION & PERMIT
BUILDING
ADDRESS
7A ' BUILDING-ELECTRICAL-PLUMBING -MECHANICAL 09024
OWNER'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
PHONE 4,
NAIVE roRa UTLETS-SWITCHES-RECEP 10.00/1.00
_ Lie No. LIGHTING FIXTURES 10.00/1.00
ADDRESS DRs - APPLIANCES-RESIDENTIAL 4.00
CONTRACTOR
PHON 7 PANELS 10.00 DATE OF APPLICATION
ARCHITECT � �Z CA, 9'0 ;I9 PANELS (OVER 200 AMP) 20,00 PLANCHECKFEE P.C.NO.
OR
ENGINEER
uc.No. SIGNS TRANS. 3.00 /
ARC Ess ENG. SPECIAL CIRCUIT 5.00 '•` PERr�yp.kpElnoN
ZIP EMP.METER OR POLE INS. 20.00 C MMII LLJJ
ADDRESS rs MOTORS SEE FEE SCH. SSP 0 (� '190C
J SERVICE CHANGE 20.00
D 0 0 TEMP.POLE 30.00 �Ify Qfy�
0 ce o LICENSED CON DECLARATION opeffin0
< u. 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
N <H Ccumnencmg with Section 7000)of Division 3 of the Business and BLDG. ELECT: PLG.
R m z Professions Code,and my license is in full force and effect. 1-14 w Contractor,C1�Q ❑ ❑
Z o w - License Classes Lie.Number.,['
F w Uatfo •a S-•fA •r�/. .
am C-_9 9-3_g5 BUILDING PERMIT
0 u a OWNER-BUILDER DECLARATION INFORMATION
soI hereby Infirm that I an,exempt from the Contrsctnr's License MISC.- REFER TO ORD
wart Law for the following reason.(See,7031,5.Businessand Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
-mom Code:Anycity orcoumy which reyuiresa permit t0construct,alter.
2 ¢ ¢Q improve,demolish,or repair any structure,prior to its issuance,also EIEC.CONTR. LIC.NO. ELEC,
a, requires the applicant for such peril to file a signed statement that TOTAL PER IT TO
A w m o he is licensed pursuant to the provisions of the Contractor's License
Hz >
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
i o Business and Professions Code)or that Ile is exempt therefrom and QTY. PLUMBING PERMIT FEE
rz r o the basis for the alleged exemption.Any violation of Section 7031.5 STORIEST P CONSTR.
o3e^ by any applicant for a permit subjects th applicant ton civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars($5001.): ,
❑ 1,as owner of the properly,or my employees with wages as BACK F LOW PROTECT. DEV ICE 4.00 f OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CONE. 5.00 i
Code: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 5,00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such mpoove-
ments are not intended or Offered for sale.If,however.the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6,00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 (EA.) 200
builder will have the burden of proving that h - . - . .
e did not build or am- BUILDING USE
Prove for purpose a sale.). INDUSTRIAL WASTE INTER. 3000 RE IND CON PB Omer
❑ I,as owner of the properly,am exclusively'contracting with . ❑ ❑ ❑ ❑
licensed contractors to co...t uct lire project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contract.,',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 contractors)licensed pursuant to SEWER-SAN V-STORM EA.200ft/10.00
lire Contractors License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sea ,B.&P.C.for[,is WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC FILE NO.
WORKERS'COSIPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy then, (Sec.3800,Lab.C.T
PolityJlNn.6{ Afp�CompanY L,t'P-/°�
O [yCenifoed copy is hereby furnished. p FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is fled with the city inspection division. MISC. REFER TO ORD.
0 Applicant YE] N❑ Y ❑ N[D
W CERTIPICATEOP I XEMPI'ON FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD20NE A.L.U.C.
LU �:, COAIPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. � N� V� NEI0. Z (Phis section need not he completed if the permit is for one TOTAL V
hundred dollar,($100)or less I
U 0 1 certify that in the performance Of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mil is issued, I shall not employ any person in any manner so as to
0w become subject to the Workers'Compensation Laws Of California.
o. Date Applicant BUILDING
>_ to NOTICE "1'0 APPLICANT. If,alter making riots Cenificate of Ex- ALTER OR ADD TO MECH. 5.00
F Z_
coalition,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 be denmed revoked. AIR HANDLING UNIT(TO 100WC.F.M.) -4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the perforntun ce of lire work for which this permit is issueA ISec �� MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 00
Lender's Name
Lender's Address el „ �- n i'.- HEATING UNIT(OVER 100,000 B.T.U.)9.50 r rya ELECTRIC
'
I certify that I rcO Trad`�hi{-a'pp`lieihtion and state that the abow, V VENTILATION FAN (SINGLE) 4.00
• information is correct. I agree to comply with all city and county PLUMBING
ordinances and stale laws relating to building construction, and BOILER-ODMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Dose,100,000 BTU)SEE FEE SCH. MECHANICAL
o bovomentioned property for inspection 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 consequence of the n.nom
Funding of this permit, MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Sognature of Applicant/COlitrac o ate 3.5-.QCC,
INSPECTOR COPY