9417 -1
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FI CATION PERMIT NUMBER
BDILounG APPLICATION & PERMIT
Az 4 os fl J G Rd BUILDING -ELECTRICAL-PLUMBING -MECHANICAL 94,17
v r �/✓0
-�[ OWNER PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
ONE
NAME
ERAcaons ,t OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.No. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 A 20.06 PLAN CHECK FEE P.C.NO.
OR
MP) p
ENGINEERARCH OR j
I.C.No. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP FrEMP.METER OR POLE INS. 20.00 �y -
AMOTORS SEE FEE SCH.
ADDRESS DREss
SERVICE CHANGE 20.00
°¢ TEMP.POLE 30.00 �/� //O S/
r O o LICENSED CON'I'kACTORS DECLARA'f10N E/
aU W I hereby affirm that I am licensed under provisions of Chapter 9 ISSUAN E GATE
N Q vt (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H w z Professions Code,and my license is in full force and effect.
z O m - License Class Lie.Number
0 z r Uate Contractor �t
a Y s ' q BUILDING PERMIT
m ¢o n OWNER-BUILDER DECLARATION INFORMATION
F:
3 y 1 hereby affirm that I ant exempt Tom the Comnactori License MISC.- REFER TO ORD
LLoa Law for thefollowing reason. 703 I.S.Businessand Professions VALUATION S/FT.
_ ' PERMIT ISSUANCE 10.00 /®
� w Code:Any mulish county whiny structure permit tots conn,,also
-a-.-O
¢ ¢ ¢ improve,demolish,Or repair 80y structure,prior to Its ISSnanCe,also ELEC.CONTR. LIC.NO. ELEC. /
Du requires the applicant for such permit to tie a signed statement that TOTAL PERMIT TO
o. w m he is licensed pursuant to the provisions of the Contractor's License
Hzi
Law(Chafter 9(com me acing wit h Section 7000)o f Division 3 of t he r2E.ytJ�r� ry0�e6
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
s i 0 "- -
¢ r o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the eppli"I'l to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than live hundred dollars(SS00)J:
O I,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00 OCC,GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sea 7044, Business and PmfeSSMS DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:I lie Contractor's License Law does nut apply to an owner of
property who builds or imprweS 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 improve-
mentsarenotln¢nded or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING uSE
builder will have the burden of proving that he did not huild or im- F ..
prove 1,as owner
of sale). INDUSTRIAL WASTE INTER. 30.00 RES IND cOIJ'-P""9 Omer
❑ I,as owner of the property,um exclusively contracting with ❑ E] ❑ ❑ ❑
licenceI contractors to construct the project(See: 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor'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 contractoAs)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ 1 an,exempt underlSec. ,B.&EC,for this WATER HEATER W/VENT 6.00
Cason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified _ ZONING ENG.SITE NO.
copy thereof(Sec.3800.Lab.C.).
Policy No. Company
O ❑ Certified copy is hemhy furnished FIRE SPRINK ENERGY T"24
FZ ❑ Certified copy is filed with the city inspection division.
O Applicant MISC.- REFER TO ORD. y ❑ N V N
m CFRIIFICA'IFOI;EXEMP'I'I ON PROM WORKERS' .. PERMIT ISSUANCE 10.00 ,FLOOD ZONE A.L.U.C.
W > COMPENSA'il=NSURANCE PLG.CONTR. LIC.NO. PLG,
CL 0 (This section need not be completed if the permit is for one TOTAL Y 0 IN
hundred dollars IS 100)or less.)
U O 1 cortil'y that in the per]urmancc of the work 1'ot which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
U Ed Date Applicant TO MECH. 5.
Q. BUILDING �� 3a
} m NOTICE"f0 APPLICAN"I': If,after making this Certificate of Ex- ALTER OR ADD 00
F Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE /S-
1, 1i
U cprovisions or this permit Shall be deemed revoked. AIR HANDLING UNIT(TO 10MCF.PA) 4.00
CONS'T'RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10000C.EM.) 6.00 SEISMIC FEE Q
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.CA HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U. 9.50
Lends,',Address ELECTRIC
I certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
• information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building eonstrumion, and BOILER-OOMP(3 H ,
hereby authorize representatives of this city to Celts upo000 B.T.U.) 6.00
n tH.P.or 100he BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to Save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs a"" "P
d expnses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accme against said City in toneruence of the
gen g (his per it. MECH_CONT. LIC.NO. MECH.
\ rornL TOTAL
.. 9�p
JG na e of Applisiantit-immlictor Date
INSPECTOR COPY
I