9440 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATION
PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADD
��// REss _ I
/� BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
9440
OWNER'S PLAN CHECK VALIDATION
NAME �1 p
14 A-R LE3 1 r ` ` �Uvr- QTYELECTRIC PERMIT FEE
vnorvE
NOMERAc7oR5 OUTLETS-SWITCHES-RECEP 10.00/1.00 V^
LIC.NO. LIGHTING FIXTURES 10,00/1.00
CONTRACTORS
tuns
ADDRESS APPLIANCES-RESIDENTIAL 4.00
NTRAC
/ PHONE PANELS 10.00 DATE OF APPLICATION
on
ARCHITECT
PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEERt
LIc,No, SIGNS TRANS. 3.00
ARC.,SS ENG, SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
ASMOTORS SEE FEE SCH. !J
ADDDRERESSS
SERVICE CHANGE 20.00 p (✓ G
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 6/0%
a o w I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
1 u rGuoucing wilt Section 7000)of Division 3 of the Business and
G Q u BLDG. ELECT. PLG. MECH.
r D i Professions Code,and my license is in f all force and effect ❑ ❑ L1o 0 y W License Class Lic.Number
Date Contractor
a x ac BUILDING PERMIT
Q ¢o a o OWNERBUILDERDIiCLARATION INFORMATION
uAxi 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
g Businessand Professions VALUATION $/FT.
F LL o J Law for the lollowin reason.lSec.7031.5, PERMIT ISSUANCE 1P.
.00 EL'
Code:Any city or county which um a res a permit to construct,alters
W 4 0 La improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIG NO. ELEC. 04� tti
4 E mM requires the applicant for such permit IO file a signed statement that TOTAL PERMIT TO
u. he is licensed pursuant to the provisions of the Contractor's LicenseLa _
R z ¢ Law(Chapter 9(commencing with Section 7000)of Divisiun 3 ofthe E4.G�7
i o Business and Professions Code)or that he is exempt therefrom and QTY, PLUMBING PERMIT FEE
I m the basis lot the alleged exemption.Any violation of5ection 7031.5 STORIES TYPE CONSTR.
i by any applicant for a permit subjects the applicant oacivil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(S500).):
Cl I,as owner of the property,or my employees will,wages as BACK F LOW PROTECT.DEVICE 4.00 OCC.GROUP RES,UNITS
their sole compensation,will do the work,and the structures 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 xLch work FIXTURES-PER TRAP 5.00 50.FT,FLOOR AREA TOTALACREAGE
himself or through his own employees.provided that such imprme-
mentsarenotintended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 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 he did not huild or hit- - . - . .
- BUILDING USE
prove for purpose ofsaleJ' INDUSTRIAL WASTE INTER3000 RES WD CON PB Omer
❑ 1,as owner of the property,mn exclusively contracting with . .
❑ ❑ ❑ O ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Prrsl'cowns Code:The CUmmetor's License Lew docs 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 will,a contractons)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Datc tatele_ WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
at
WORK 17RS'COMPENSATION DECLARATION WATER TREATING EQUIP. - 5.00
I hereby affirm that 1 have a certllicate of consent to sell-insure.
or a certificate of Worker;Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.CJ.
Policy No. -Company
O ❑ Certified copy is hereby furnished. FIRE BpRINK ENERGY T 24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
F O Applicant V N V NEJ
m CERTIFICATE 01'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10,00 FLOOOZONE A.L.u.C.
W 7 C04I?NSA'f1ON INSURANCE PLG.CONTR. LIC,NO. PLG. V� NEI V� N[:]11 D (This section need not be completed if the permit is for one TOTAL
� Z hundred dollars IS 100)or less.)
U O I c'ertif'y that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL If- mit is issued,I Shall not employ any person in any manner so as to
Q W become subject to the Workers Compensation Laws of California.
C. Date ApplicantALTER OR ADD TO MECH. - 5.00 BUILDING
>_ to NOTICE 'I'O APPLICANT! If,after Looking this Certificate of I?x-
FZ emption,you should become subject to the Workcrs 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 deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 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(TO 100,000 B.T.U.) 8.00
Lender's Name HEATI NG UNIT 100,000 B.T.U.)9.50 Q 0-0
Lender's AJdress ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• information is correct. I agree to comply with all city and county PLUMBING
ordinances and lute laws relating to building construction, anJ BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives for ins of this city es emcr upon the BOILER-COMP love,100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property tativsp ofth i purposes.
OVI) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs nrand expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way acee against said City in consequence of the
granting Of this permit. MECH.CONT. LIC.NO. MECH.
TorAL TOTAL
re scant tr for ale
INSPECTOR COPY