9202 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
PERMIT NUMBER
BUILDING
APPLICATION PERMIT
ADDRESS Lyl BUILDING - ELECTRICAL-PLUMBING-MEMECHANICAL
9202
PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
N
CONTRACTORS
ONTRACTOa NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO. LIGHTING FIXTURES 10.00/1.00
CONTRAS
ADDREACTORs APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEEfl
uc.No. SIGNS TRANS. 3.00
rJ
ADDRESS ENG. - SPECIAL CIRCUIT 5.00 PERMt,'f� L ION
zip EMP.METER OR POLE INS. 20.00 S {�
APPLICANT'S ( MOTORS SEE FEE SCH.
/I
ADDRESS /�L I 5 '1 rX s-e- / J
V , ,_ - C !y SERVICE CHANGE 20.00 tp C�pe�{jp0
o o LICENSED CON TRACTORS DECLARATION TEMP.POLE 30.00 Ci�Y 0I
< u I hereby ufl it that I am licensed under provisions of Chapter 9 ISSUANCE DATE
h1
(commencing with Section 7000)of Division 3 Of the Business and
< u „BLDG. ELECT. I PLG. MECH.
H N i License Cha Code,and my license is in full force and effect. ❑ ❑ ❑
2: o w - License Class Lia Number
o IJutc Contmdpr '
¢ m E BUILDING PERMIT
¢ ¢ ¢ OWNER-BUILDER DECLARATION
o A" MISC.- REFER TO ORD INFORMATION
X
3¢ H 1 hereby affirm That l am exempt from the Contractor's License VALUATION S/FT.
.. o¢ Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 10.00
I > E Code Any city orcounty which ret,musa pernit to construct,alter.
¢ ¢ 1 O improve,demolish,or repair any structure,prior 10 its issuance,also ELEC.CONTR. LIG.N0. ELEC.
D LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
n w w he is licensed pursuant to tire provisions of the Contractor's License
In z i Law(Chapter9(commencing with Section 7000)of Division 3 of01e
a Business and Professions Code)or that he is exempt therefrom anPLUMBING PERMIT FEEif
¢ r c the basis for the alleged exemption.Any violation of Section 7031.5 TORIESIt YynONSTRi
p ; m by any applicant for a permit subjects the applicant Ica civil penalty ALTER-DRAIN -WATER IEA.) 5.00 r
of not more than five hundred dollars(5500).):
❑ I,as owner of the Properly,or my employees with wages ns BACK F LOW PROTECT. DEVICE 4.00 0 c.GR u E .UNITS
their vole 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 docs not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT,FLOOR AREA TOTAL ACREAGE
e himself or through his own employees,provided that such nmimprove-
es are not intended 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 EASYSTEM OVER 4 (EA) 200
builder will have the burden of proving that h - . - . .
ime did not build or - BUILDING USE
prove for purpose of sale.). RE IND CON PB Other,
me�gq.s I,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 El El El El
IicLrased contractors to construct the project(Sec. 7044, Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does nal apply
to an owner of properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to SEWER-SAN V-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
O lam exempt undo Se�,tl.&YC.for this WATER HEATER W/VENT 6.00
(Pana,
Own,L'ri -/ � Date z./�.- WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
woRKElis'CO M PFNSATl(N uECLn Rn'n LN WATER TREATING EQUIP. 5.00
�1 hereby affirm that I have a certificate of consent to self-insure. ZONING6r a certificate of Workers-Compensation Insurance,or a cert I, ENG.SITE NO.
✓� copy thereof(Sec.3800,Lab C.).
Entry No.-Company-
0
o. CompanyO ❑ Certified copy is hereby furnished FIRE SPRINK ENERGY T"24
Z Z r❑ Certified copy is tiled with the city inspection division. MISC.- REFER TO ORD.
a.F O/ Applicant Y[:) NV [:) NE]
ft, N CE R'I'D-CA'1'1:OIs EXEAIP PION FROM WORKS RS' PERMIT ISSUANCE 10.00 EL000 zoNE A.L.U.C.
LU > (70.41;N'SATION INSURANCE PLG.CONTE. LIC.NO. PLG.
0 IThis section necd not be completed if the permit is for one TOTAL v N� Y N�
hundred dollars(S 100)or less,)
U O l�certify that in the performance of the work for which this per. QTY. MECHANICAL PERMIT s FEE FEE SUMMARY
UL l- mit is issued.I shall ,of employ any person In any manner,so as to
O Ubecome subject to the Workers'Compensation Laws of Calil"ornia.
UJ y Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING QQ_
} W
NOTICE 10 APPLICANT': If,alter making this CerliGcale of Ex-.
F Z cntption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK 2�y
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT ITO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=01C.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.). _ HEATING UNIT ITO 100,000 B.T.U.) 8.00
Lender's Name -- �- o - Al_q Z+ 'E.-
Lender's Address HEATING UNIT(OVER 100,000B.T.U.)9.50 ELECTRIC
I certify that I huvCr eJ tthis upplic ioo vn I sta c 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 construction, and BOILER-OOMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP (Op, 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep humurss the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against-said ity in consequence of the PERMIT ISSUANCE 10.00
granting Of thi permit. /� / MECH.CONT. LIC.NO. MECH.
'� TOTAL TOTAL
lign olre'o A phi ant ntnicto - ,17 e
INSPECTOR COPY