9103 APPLICANT TO FILL IN INFORMATION WITHIN R j,@D LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT 1 DENTI FICATI ON f- PERMIT NUMBER
IWILDING APPLICATION & PERMIT 9193
X aooREss O -` -
/Vl BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
y OWNER'I PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
.ONE
CONfRXtTOR s 3.?7/O7 UTLETS-SWITCHES-RECEP 10.00/1.00
NAME
uC.NO. LIGHTING FIXTURES 10.00/1.00
c-o T 's PPLIANCES-RESIDENTIAL 4.00
ApDR s
{ J PHONE PANELS 10.00 DAT E OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 'A�P,LAN CHECK FEE P.C.NO.
OR \
ENGINEER
uc.No. SIGNS TRANS. 3.00
ADDRESS ENc. \ SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
z.P TEMP.METER OR POLE INS. 20.00
APPLICANT'Sr
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
��woo LICENSED CONTRALTO S DECLARATION TEMP.POLE 30.00 /a-J
a v I hereby affirm t1 1 oat lirenud is,provisions of Chapter 9 ISSUANCE DATE
y< m Immmencing with Section 70001 of Divbion3.of.the Business and BL G. ELECT. PLG. MECH.
F m z Professions C.A,a d my license is in full force and c ,X/ ❑ ❑ ❑
z o m - License Class Lie.Number
4 [)lie f���� Contractor
¢ y f BUILDING PERMIT
¢ ¢ w a OWNER-BUILDER DECLARATION INFORMATION
wct A MISC.- REFER TO ORD
;a. m 1 hereby adfirm that I am exempt from the Contractor's License VALUATION $/FT.
s- LL o J Law for the following reason.(Sec.703 L5,Business unJ Professions PERMIT ISSUANCE 10.00
Cade:Any city or county which requiresa permit to construct,alter, -
rt to ¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
-706
O a,requires the applicant for such permit l0 file a signed statement that TOTAL ! PERMIT TO
n w m y he is licensed pursuant to the provisions of the Contractor's License '
r
Late(Chapter 9(cotemencifeng with Section 7000)of Division 3 oflhe "�
¢ Business anti Profession,Code)or that be is exempt Iheefmnt and QTY. PLUMBING PERMIT FEE
¢ fi
the basis for the alleged exemption.Any violation of Section 7031.51 RIES -TYPE ON TR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-GRAIN -WATER IEA.) 5.010 of not more than Ove hundred dollars(S500).):
Cl I,as owner of the property,or my umplayees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their Solt compensation,will du ru
the work,and the stcturci,not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contract.,'.,License Law does not apply to an owner of
properly who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
.E, himelfor though his ow nmprovided that sch it.provo--
nenlsare not intended or offered forsal .hoec(hebuil
GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement Is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 -BUILDING SE
builder will have the burden of proxing that he did not huild or im-
proveforpurposeofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND PB Omer
❑ 1,as owner of the property,am exclusively comm,Rc,wish 1:1 ❑ El 1:1
licensed contractors to constnict tire project(See. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSOR 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 contract...IS)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00 w.
the Con lr,eDn',License L.W. TRACT NO. PARCEL NO.
U I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
mason
Owner Dale WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO.
WORKERS'COMPENSAT1ONDECLARA'I'ION WATER TREATING EQUIP. ;5.00 , ^
I hereby affirm (hal 1 have a certificate,,'consent In wlf-insure. ZONING
or a certificate of Workers'Compensation Insurance,or a certifiedENG.SITE NO.
copy thereof IS 3500.Lab.C.L q ��B //- y
Volicy No/%1-4_QCjQyQy'.y}yy---grs-Y QQ_(,�.«(-(.6-
O _❑ CerII ceIf c p t heti C
FIRE SPRINK ENERGY T-24
Zp/ PD1-Cepli )tified copy is filed with the city inspection division. MISC.- REFER TO ORD. v N v ry
rn PERMIT ISSUANCE 10.00 ❑ ❑ ❑ ❑
c - UER'FIl:1CA'I'EOF iXEM'fION FROM WORK FRS' FLOOD ZONE A.L.UC.
U CONIPENSAI'ION INSURANCE PLG.CONTE. LIC.NO. PLG. v N V NE]Z (This section need not be completed iChe permit is for one TOTAL
hundred dollars(S I DO)or less.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F chit is issued,I shall Red employ any person in any I»unner SO as to
U becomesubject to the Workers'Compensation Laws of California. -ter- BUILDING
ED Date Applicam ALTER OR AD-D Ta`N1E-C�F'`��� 5.00
} m NOTICE 'f0 APPLICANT: If,after making this Certificate of Iix-
SO-
I.. Z umption,you should become subject(o the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply will FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.NL) 4.00 4v 03
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.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 his of the work to)wlt;cI ( permit is i.oved(Sec. MICROFILM
3097,Civ.C.L YY,, HEATING UNIT(TO 100,000 B.T.U:) 8.00
'' YY 11
Lender's Nume HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lcndur's Addre
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 stale laws relating to building construction, and BOILER=COMP(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 inspec0oo purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(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
granting ufthisg /
RiMECH.CONT. LIC.NO. MECH..
TOTAL
TOTAL D�
Signature of Appliant/Contmct.r Date s _
INSPECTOR COPY
_ 1 I