C9358 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
I BUILDING PROJECT IDENTIFICATION - PERMIT NUMBER
DILDiNG -APPLICATION& PERMIT 1 t
OOREss L..
, ' - -
BUILDINGELECTRICAL-PLUMBINGMECHANICAL 9358
OWNER'S �•'x L(J'V PLAN CHECK VALIDATION
NAME It\� QTY. ELECTRIC PERMIT FEE
• ��PHONE �
f CONTRACTOR"5 •
UTLETS-SWITCHES-RECEP 10.00/1.00 d'b 13U 6f-?
uc.No. LIGHTING FIXTURES 10.00/1.00 C4'+
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00 S"1 " r sem•
A DREss
(- 9NE PANELS 10.00 DATE OF APPLICATION
Aon hT CT - PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO:
ENGINEER
LIC,No. SIGNS TRANS. 3.00
AARCHOR DDRESS ENG. SPECIAL CIRCUIT .5.00 'APER MIT VALIDATION
ZIP EMP.METER OR,POLE INS. 20.00
Aar$
ADDDRESSDRESSMOTORS SEE FEE SCH.
SERVICE CHANGE _ 20.00
w o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
¢ v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
a w (commencing with Section 7000)of Division 3 of the Business and BLD ELECT. PLG. MECH.
mi Professions Co y is rete is in full foreapnd !feel. I
z o m - Licenu Cla�'�Lia Number �. 4P
0 w r w 'Date Contractor_ -
¢ m s < J � n � BUILDING PERMIT
¢ 0 d iia-nuarniR DELL I INFORMATION
X ; n m -I hereby affirm that I am exempt from the Contractor's License MISC.- v REFER TO ORD _ VALUATION- $/FT.
uoj Law for the following reason.(Sec.7031.5.Businessand Yro(essions PERMIT ISSUANCE 10.00 !/Z
= w Code'.Any city or county which requires a permit to construct,alter,
�D/'�•
¢ ¢a improve,demolish,or repair any structure,prior to its Issuance,also ELEC.CONTE. LIC.NO. ELEC. [/
al
a, O¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
m he is licensed pursuant to the provisions of the Contractor's License
l F z a
Law(Chaplet 9(commencing with Section 7000)of Division 3 of the y
3 i 0 Business and Professions Code)or that lie is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r m the basis for the alleged exemption.Any violation of Section 7031.5 - 5 ORIS T, P cum
a ; - by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars(SS00).): ALTER-DRAIN& VENT-WATER (EA.) 5.00
* ❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole 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 u
Code:The Contractor's License Law does not apply to an owner of h`
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 so.FT.FLOOR AREA TOTAOACREAGE
himself or through his own employees,provided that such improve-
• �- meets are not pleaded 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 EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving:hat he did not build or im-
prove forof sale.). INDUSTRIAL WASTE INTER. 30.00 E I❑ ❑N PB F-1 '.
o❑
❑ I,ass owner owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
unit Professions Code:1'1he 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 contracto ls)licensed pursuant to SEWER-SANITARY-STORM V-STORM EA.200ft/10.00 TRACT NO. .PARCEL NO.
the Contractor's License Law.
❑ Iumexemplundur Sec. ,B.&PC.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO:
WORK EiRS'COM PENSATION DECLARATION WATER TREATING EQUIP.' 5.00
"1 heruhy affirm that I have a certificate of.....sent In ulGinsun', -- ZONING ENG.SITE N0.
or"a certificate of Workers Compensation Insurance.or a certified
arp§Ther of Ise . �1 l&b.C.I
Policy N play s
O Cc Is I by(ural.u•
FIRE SPRINK ENERGY T-]4
Z Zi ❑ Ccr' ropy i idea with tic city ire cct ion division.
APPllca r.C_. MISC.- REFER TOO D. Y[] NE] YE) NE]
� N
FLOOD A.L.CIRTIFCATIOF EXEMPTION FRWORKIRS• PERMIT ISSUANCE 100
I U.C.
LU > COMPENSATION INSURANCE PLG,CONTR. CIC.NO. \ PLG. V N� V N�
CL Z( This section need not be completed if the permit is for one TOTAL
hundred dollars(S 100)or Ic,,)
L) O 1 certify that in the performance of the work for which thQTY- MECHANICAL PERMIT FEE FEE SUMMARY
LL l- mit is issued,I shall not employ any person in any manner,."fen
U become subject to the Workers'COmpcusalion Laws of California.
O i Date Applicant ALTER OR.ADD TO-MECH. 5.00 BUILDING
} 0 NOTICE' TO APPLICANT: If,after making this Certificate of Ex-
~ Z emplion,you should become subject to the Workers'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.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 porn.it is issued(Sec. MICROFILM
3097,Civ.CJ. HEATING UNIT (TO 100,000 B.T.U.k�7 8,00
Lcnder's Name i HEATING UN IT 100,000 B.T.U_.)9.50 (/d
Lender's Address ELECTRIC �
I certify that l hove-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 V'/
ordinances and state laws relating to building construction, and BOILER-COMM H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100 U00 RTU(SEE FEE SCH. MECHANICAL (Jf1
above mentioned property for inspection purposes. 1
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities, 'udgments, cost anJ expense which PERMIT IS UANCE 10.00 (/� CONST.TAX
may;iu any 'ay accrue ag est said City consequen of[he
Rt -0f lh pen it. ECM.CONT. LIC.NO. M H.
G �� ofAL TOTAL a Seo d3
g pk nuc htrac U
INSPECTOR COPY '; -