9371 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY PERMIT NUMBER
BUILDING BUILDING PROJECT lDENTIFICATION APPLICATION & PERMIT
_ 9371
Aoo
[BUILDING- ELECTRICAL-PLUMBING-MECHANICAL
OWNER PLAN CHECK VALIDATION
NAME �s DTV. ELECTRIC PERMIT FEE
aNE
NAME Ac ROUTLETS-SWITCHES-RECEP 10.00/1.00
LIc.NOQ Sba4 A LIGHTING FIXTURES 10.00/1.00 O
A o 's APPLIANCES-RESIDENTIAL 4.00 O
nooREss , j, I
PHONE73 4?ir 2M
72-
PANELSlO.00 S DATE OF APPLICATION 1
OR AIRCRITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE D.C.NO.
ENGINEER
LIc.NO. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5.00 PER4Q VALIDATION
ADDRESSZIP EMP.METER OR POLE INS. 20.00 t!A~o/
" MOTORS SEE FEES SEP QC
'
ADDRESS ���
SERVICE H ' 20.00 {� 5
Dao LICENSED CONTRACTORS DECLARA N TEMP.POLE 30.00 O[C�� /�
a v u I hereby al'1'inn that 1 am licensed under provisions of Chapter ISSUANCE4j9e f
N a a- (commencing with Section 7000)of Division 3 of the Business and BLDG. EL PLG. MECH.
r w z Professions Code,and my license is in full Force,and effect ❑ ❑ ❑
0 m o License Class Lic.Number
r• m r J Date Contractor
a y re I
tc ¢o a O OWNER-BUILDER BUIL I G PERMIT
R-BUILDER DECLARATION IN RMATION
wg LL I hereby affirm that I am exempt from (lie Contractor's Liccnsc MISC,- REFER TO ORD
o¢ Law for the following reason. 7031.5.Business and Professions pERM1T ISSUANCE 10.00 p VALVA ON $/FT.
� LL Code:Any city or county which requires a permit to construct,alter,
¢ ¢ ¢ 40 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
i w m u requires the applicant for such permit to file a signed statement that I TOTAL PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License
r- z¢
Law(Chapter 9(commencing with Section 7000)ofDivision 3 of the
i O Business and Professions Code)or that he is exempt thcrcOnm and OTV. PLUMBING PERMIT FEE
ce H o the basis for the alleged exemption.Any violation of Section 7031.5 STORI PE OrvSTR.
Ate _ 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(5500).1:
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00 OCC.GROUP RES.UNITS 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,COND. 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 so.PT.FLOOR AREA TOTAL ACREAGE
• himself re through his own employees,provided that such im building
or nts improvemenotnt tended or within
rorefor
year
If,however,tire the owner-
GAS-EA.SVSTEM-11NC.4 OUTLETS 6.00
or improvement is sold within enc year oft 11,completion the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2:00
builder will have the burden of proving that hu did mol M1uiIJ or im- BUILDING USE'.
prove for purpose of sale)' INDUSTRIAL WASTE INTER. 30.00 R IND CON PB Omer
❑ L as owner of the properly,um exclusively contracting with El ❑ ❑ 1:1licensed contractors to constant the project(Sec7044,. Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCELNO.
and Professions Code:Thdoes e Contractor's License Law duos not apply
to anowner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a conlrtraemr(s)licensed Pursuant to SEWER-SANITARY-STORM EA.200tt/10.00
the Contractor License Law. TRACT NO. PARCEL N0.
❑ Iain exempt under Sec.-.B.&P.C,for this WATER HEATER W/VENT 6.00
reason
9wne, Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE No.
`/44,42-- '�S'PO PE NSATION DECLARATION WATER TREATING EQUIP. 5.00
\,
hereby affirm that I have a ce Compensation
of current o a r insua, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance or a cenificd
copy thereof(Sec.3804 LaBC
Policy No. Company in ,
❑ Certified copy is hereby 1 r I led I FIRE SPRINK ENERGY T 24
Certifie o y is Til• ith the city inspection division.
fI / I MISC.- REFER TO ORD.
Z
icant7 !' � d ��6y V❑ N❑ V ❑ N❑
~ 00 ti
Lu Cki R'I'II%CC0li OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10. FLOOD ZONE A.L.U.C.
W COMPENSAATIOIO N INSURANCE PLG.coNTR. LIC.No. PLT Y❑ N❑ Y ❑ N❑
b�� Z LCI ou died
dollars
Send not be complete) if the permit is for one TOTAL '
hundred dollars fit the pe form
0101• mit is
that h 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 is to
U w become xlblen In the Worker Compensation Laws of California.
Q. Date Applicant BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
Z_ emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Cuda, you nest tiirthveith comply with FEE
U such provisions 0r His permit shall he deemed revoked. AIR HANDLING UNIT TO I0=C:F.ViW 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10.000C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is It 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.L 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 I have read this application andstate that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with 411 city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMPl3H.P.or100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon Ihu BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly for inspection purposes.
(We) agree to save, indcnmify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way a ue again, said C'ty in consequence of the PERMIT ISSUANCE 10.00
granting of this pe riL MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
S n n actor
INSPECTOR COPY
' _ I