C9450 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PE ONLY
.t T
BUILDING PROJECT IDENTI FICA PERMINUMBER
BUILDING APPLICATION & PER&
9450 4 5 o
�( ADDRESS
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL `uJ
1 OWN a' _ PLAN CHECK VALIDATION
\ NAME CIO 9 QTY. ELECTRIC PERMIT FEE
INII, III-:'• L ONE 0
CONTRACTOR
NAME 1Q UTLETS-SWITCHES-RECEP 10.00/1.00 O
NAME
LIC.No. LIGHTING FIXTURES 10,00/1.000
!• ARESOTORs
DDPPLIANCES-RESIDENTIAL 4.00 1
CONTRA
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.N0.
OR
ENGINEER
%I)APLIZE GIL R LIC.No. SIGNS TRANS. 3.00
ADDRESS E"G SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
zIP EMP.METER OR POLE INS. 20.00 /1��
APPUC rs MOTORS SEE FEE SCH. /N`(f,"�j'��-i
ADORES
I;mr ' SERVICE CHANGE 20.00 /
w Q z TEMP.POLE 30.00 �S
,00 U(�ENSI:D CONTRACTORS DECLARATION
a U u I hereby affnn that I am licensed under provisions of Cbaprer 9 ISSUANCE DATE
o "' (commencing with Section 7000)of Division 3 of the Business and - ,
Q n - "BLDG. ELECT. PLG. MECH.
Professions Code,and my license is in full force and effect. y ❑ ❑ E]!. z o ov - .License Class Lic.Number
Date Contractor
o to
Nr ay s BUILDING PERMIT
Y ¢ ao too OWNER-BUILDER DECLARATION INFORMATION
[-.w g LL r I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
E� a. 04 Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
a rNY � Code:Any City urCounty which requires a permit to construct,alter, Q OOD.�I
S^¢ ¢ < 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
i LL requires the applicant for such permit to file a signed statement that - TOTAL 30' PERMIT TO
w he is licensed pursuant tothe provisions of the Contractor's License
Law(Chapter 9(cummenciogwith Section 7000)of Division 3 of the
a Rosiness and Professions Code)or that he is exempt therefrom,and OTY. PLUMBING PERMIT FEE
r m the basis for the alleged exemption.Any violation ol'Scct ion 7031.5 TORIE ..
-
_5TY E'CONSTR.
by any applicant bur u morril subjects the applicant to u civil penally ALTER-DRAIN -WATER (EA.) 5.00
't of nol m en,than five hundred dollars(SS00).): f ,
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will Jo the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale ISe•2f 7044, Business:ed V ol'essions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
�. Code:The Contractor's License E w does 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
himodf or through his own employees,provided that such on preme.
P^•
.,Is 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- GA -EA.SYSTEM-OVER 4 IEA.) 2.00 0
r builder will have the burden of proving that he did not build or im- BUILD,NG USE
prove for purpose of sale.). IND O STRIAL WASTE INTER. 30.00 R
- E IND CON PB Omer
O 1,as owner of the property,am exclusively contracting with E] E]
E]
licensed contractors to construct the project(Sec 7044,Business LAWN SPRINKLERS-1 INCAss ESsoRS 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-OV ER 5(EA.) 1.00
o- contracts for such projects with a contractors)licensed pursuant to SEW ER-SANITARY-STORM EA.2001t/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ In it,exempt under Sec.-,B.&P.C.for this
reason WATER HEATER W/VENT 6.00
'^•
Owner �I Date $ WATER SYSTEM 5.00 ACC.DATE ACC.FILENO. -
,I:. WORKERS'("( dPENSA'I'IVI DECLARATION-,' //`'_ WATER TREATING EQUIP. 5.00
I hereby 11hrin that I have a certificate o1consent to X11-insure. ' ZONING
or a certif¢a,of Workers'Compensation Insurance,or d certified --�-- --- ( ,..� ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.). \, l
Policy No. Company 1
❑ Certified(" hereby furnish cd. - FIRE SHRINK ENERGY T-24
!. Z Z ❑ anNcopy Certified copy is tiled with the city inspection division. MISC.- REFER TO ORD.O ApplicantYE] N❑ I v E) NE]
Cr W CERTIFICATE OP EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 ' FLOODZONE A.L.U.C.
' LU > COh1PENSATION INSURANCE; PLG.CONTR. LIC,NO. PLG. Y� N[] V� NE]CL 0 (This section need not be completed if the permit is for one TOTAL
hundred dollars IS 100)or less.) ._-
-- U O 1 certify that in the performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
E' LL I- mil is issued,1 she]] not employ any person in any manner sr as to
OW become subject to the Workers'Compensation Laws of California.
B. Dae Applicant BUILDING
} W NOTICE;TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00 /
F Z_ emPtion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Cade, you must forthwith comply with FEE
U such provisions or B,is permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IOAOOC.EM.) 6.00 SEISMIC FEE
t I hereby affirn, that there is u construction lending dganCY lire EXHAUST HOOD(WITH DUCT) 5.00
the m,tmn r,,cc of the work I'or which this permit is D,ucd(Sec MICROFILM
3097,Civ CA HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lendcr's'Name HEATING UNIT 100,000 B.T.U.)9.50 �. (�
Leader's Address .E LECTR I C
I cerlily that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 7
mfoncecorrect. 1 agree tcomply with a1 city and county BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00 PLUMBING OC�
ordinances
s and slate laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP (Overt00,000BTU SEE FEE CH-1 MECHANICAL
above-mentioned property for inspection purposes. - _
(We) agree to save, indemnify and keep harmless the City of MISC.= -'�FER TO ORD'Y _•/
Cupertino against liabilities,judgments, costs and expenses which PERMIT-IDausuvUE"--•^J 10.00 L--y CONST.TAX q
may in any way accrue against said City in consequence of the
grant g of(his pen 1. MECH.CONT. LIQ NO. MOTAL
TOTAL
Si na t e of pp cent/C ntracl at {
INSPECTOR COPY ><"