9173 APPLICANT TO,'FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY X0,3
BUI LDI NG{PROJECT I DENTI FICATI ON - PERMIT NUMBER
BUILDINGAPPLICATION & PERMIT
ADDRESS �� ��
ADDRESSSS
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
O ERS PLAN CHECK VALIDATION
NAME 0TY. ELECTRIC PERMIT FEE
PHONE
cONT ac s OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME
S /�er✓,_e'e C. 1C.No. 1'/.s3LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
ADDRESS PPLIANCES-RESIDENTIAL 4.00
'/�
6 �S ( tiQ��GS S�PHDNECI:5s PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE v.c.ND.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
nRCH.ORness ENG. SPECIAL CIRCUIT S.QQ PERMIT VALIDATION
rm
ZIP EMP. METER OR POLE INS. 20.00 n
APPLICANTS MOTORS SEE FEE SCH. C/
ADDRESS A/ 7-
W'. Cf1Cre5� Sf Sk/ S//ol- SERVICE CHANGE 20.00 '/�/� S�
SE
o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 ,
¢ swi o I humby affirm that I an, li«nsSit under provisions of Chapter 9 ISSUANCE DATE
m, w [commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F y z I'rofessums Code,and Con license is in full force and cff• ❑ ❑ ❑
z o w - License ClassLec.Number
9 so F ° Date Contractor Cmttnctar
so a Y E BUILDING PERMIT
¢ ¢ w ¢ OWNER-BUILDER DECLARATION
0WU MISC.- REFER TO ORD INFORMATION
X
; u y 1 hereby.Itirm that I Con exempt frons the Contractor's License -
.. oj Law for followiogrtasom.(Sec.7031.5.Business and Professions pERM1T ISSUANCE 10.00 VALUATION SIFT.
� - Code:, city or county which requires a permit to construct,alter,
¢ ¢Q 0 improve, •molish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
US -°u requires the plicant for such permit to file a signed statement that V TOTAL PERMITTO
<t w m he is licensed usuunt to the provisions of the Contractor's License -
HZQ
Law(Chapter') -ommcncing with Section 7000)of Division 3 of the �L VM a�aV
Bus'Tress and Pro Bions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
¢ H o .the bd5is fpr the aIle m exemption.Any violation pfStttion]031.5 STORIES TYPE CONSTR.
To
ate _ by any applicant for omit subjects the applicant toacivil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than live h fired dollars(5500).):
❑ 1,as owner of the sroperty,or my employees with wages as BACK F LOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation, 'll do the work,and the st,Lctrtre is not
intended or offered fie sal (Sce. 7044, Business and professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:'f he Contractor Licen Law docs not apply to an owner of
property who builds or improv' thereon,and who does such work FIXTURES-PER TRAP RRR / SO.FT.FLOORAREA TOTALACREAGE
himself or through his own empl ses.provided Ihal sucli improve- _.
ments are not intended or offered r sale.If.however,the building GAS-EA.SYSTEM-J1NC.40UTLETS 6.00
or improvement is sold within one 'r of completion.the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of provin that he did not build or ins- REB IND CON PB Omar
prove l or purpose of sale.). , INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exs. Isively contracting with ❑ ❑ ❑ ❑ ❑ 1
licensed contractors to construct the proje (Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's Lure Law docs not apply '
town uwner Of properly who builds or IT
thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
Contracts for projects with a contracHms)lix'nsed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
O lam exempt under Sec. ,f.11:1'.C.for this WATER HEATER W/VENT 6.00
reason ��
Owner Date a WATER SYSTEM 5.00
ACC.DATE ACC FILE NO,
WORK E RS'COMPENSATION D17CLARATION WATER TREATING EQUIP. 5.00
I herebyaffirm Ihm I have a scHilicatc of consent to self-insure, s ZONING ENG.SITE NO.
or u certificate of Workers'Compensation Insurance or a certified
copy thencof(See 3800.Lab.C.).
Policy Nn ompany t� f
O ❑ CerhDred copy rs hereby furnish FIRE SPRINK ENERGY T-24
-z Z Certified copy is filed with the city insp-cti n division.
M ISG.- REFER TO ORD.
D
P5
/- V ❑ N❑ V ❑ N❑
XN CERT'IFICAT'1?OF EXEMPTION FROM w KHRS, PERMIT ISSUANCE ,DAO fh FLOOD ZONE A.L.U.C.
UJD COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. w Y❑ N❑ V ❑ N❑
Z (Th' uc tion need not be completed if the permit is for one / °TAL all
hundred 'nf S100)or less)
U O I ceHlfy tha the performance of the work for which this per CITY. MECHANICAL PERMIT FEE FEE SUMMARY
H Inil is issued,I Shu t entpluy any person in any Inanner so as m
U W become subjectmthe ers'Compensatio.Laws of California. BUILDING
Ed Date APpNcnn ALTER OR ADD TO MECH. 5.00
} N NOITCF-TO APPLICANT: If,al taking this Certificate of L'x-
F Z errPtion,you should become subject to fi`Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must 721rtf�with comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSI'RUCTION 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 permit is issued(Sec. MICROFILM
3097,Civ.C.): HEATING UNIT(TO 100,000 B.T.U.) 8.00
L' de.',Name HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's revs
Icertily that 've read this anpl kation and sVnethm the.,b VENTILATION FAN (SINGLE) 4.00
•
information is corn agree Io comply with all city anJ manly PLUMBING
ordinances and state laws ting to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 hereby authorize representative his city to enter upon the BOILER-COMP to 100,000 BTU)SEE FEE SCH. MECHANICAL.
above-mentioned property to
inspection oscs.
(We) agree to save, indemnify and keep ha dens the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
gmntingoClhisPemfl. MECH.CONT, LIG NO, MECH.
TOTAL TOTAL
Ignature of Applicant/contractor Datums
INSPECTOR COPY