C9419 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION FEW IT NUMBER
ROILDING APPLICATION & PERMIT "
ADDRESS 9419 A 1 9 .
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 1p
wrvER
NAME Mf J rv. r5 07C QTY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION
C� P 3'6 6 ` �3 3` 2.
NAMERACiORS UTLETS-SWITCHES-RECEP 10.00/1.00 J
LO,NO, LIGHTING FIXTURES 10.00/1.00
CONTRAC
ADDRESS TDRyS PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT ai, PLAN CHECK FEE P.C.N0.
OR is PANELS (OVER 200 AMP) 20.00
ENGINEER y
LIC.NO. SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION
ACREEssy 's`�"' SPECIAL CIRCUIT 5.00 'ms`s .
'" -' ZIP TEMP. METER OR POLE INS. 20.00
APPLICANT'S -
ADDRESS! MOTORS SEE FEE SCH. /J
)' - 1 / SERVICE CHANGE 1, 20.00
0 in z p
r o o y LICENSED CON'I'RACTORS DECLARATION e TEMP.POLE 30.00 p � �S
v 1 hereby'aff nn that I am licensed under provisions o(ChaE er9 ISSUANCE ATE
m a H (commencingG.with Section 7000)of Division 3 of the Business and BLDELECT. PLG. MECH.
F w z Professions Code,and my license is in full force and effect.
zo 0 License Class Lic.Number
m tiDate_Contractor i
MII: M at J / BUILDING PERMIT
o w OWNIi R-BUILDER DECLARATIONINFORMATION
wLL H 1 hereby Or.... that I am exempt from the Contractor's License MISC.- REFER TO ORD '
FU04 Law forthe following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCEVALUATION S/FT.
- Code:Any city orommy which requiresa permit to construct,alter, 10.00 / 00 /1/
Y ELEC.CONTR. LIC.NO. !.,v
li ir e o improve,demolish,or repair any structure,prior Io its issuance,also ELEC.
C at requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
n w m Iw is licensed pursuant to the provisions of the Contractors Lice"m
rzaLaw(Chapter 9(Commencing with Section 7000)ofDivision3Riffle �� Ca✓c2
x O Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE T 0 l••
y- the basis for the alleged exemption.Any violation of-Section 7031.5 STORIES .TYPE CONSTR.
u ; _ by any applicant for a permit subjects the applicant to a civil penally
of not more than five hundred dollar,(S5000.): ALTER-DRAIN& VENT-WATER (EA.) 5.00
❑ I,as owner ofthe property,or my employees will,wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the sucture is not OCC.GROUP RES.UNITS
tr
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 such work FIXTURES-PER TRAP 5.00SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve.
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 6.00
Or unprovemenl is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im. BUILDING USE
Prove for purpose of sale.). RES IND CON PB Ober
❑ 1,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑
licensed contractors to construct the protect(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS 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 contraclons)licensed pursuant to SEWER-SANITARY-STORM EA..200ft/10.00
the Contractor's License Law. '� " TRACT NO, PARCEL NO.
❑ I am exempt under Sec. ,BAP.C.fol this WATER HEATER W/VENT a 6.00
Ow,vnerw
r . Dat WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK E RS'COM PENSA'[ION DECLARATION WATER TREATING EQUIP. nj 5.00
I hereby affirm that 1 have a certificate ofcmms of to sal Ginsmy. R `
or a certificate of Workers'Compensation Insurance,or a Certified S ZONING ENG.SITE NO.
copy thereof(See.3800,Lab.C).
Policy No. Company
❑ Cenificd copy is hemby funtishcd' �FIRESPRINK ENERGYT 24
Z Z ❑ Certified copy is fled with the city inspection division. ❑ ❑
F O Applicant MISCC]- REFER TO ORD. y N Y ❑ N
CC N CERTII°1CA'f E 0171iX EM PTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
CL 0 (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
::) Z 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
U mit is issued,I shall not employ any person in any manner so Io
O0UJ
become subject to the Workers'Compensation Laws of Californiais.
Q_ Data Applicant ALTER OR ADD TO MECH. 5.00 BUILDING aO f
} W NOTICE TO APPLICANT: If.after making this Certificate of Ex-
F Z_ empiion,'you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
pmviiisas 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)000CF.M.) 4.00
` CONS'IRUC'I'ION LENDING ACI?NCY AIR HANDLING UNIT(OVER I0,000C.F.M.) 6.00 SEISMIC FEE SU
I hereby affirm that there is aconstruction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work Im-which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lcndcr Address H EATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I C /
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
into ordinances n correct. 1 agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws !elating m building construction, and
hereby aullorentione a representatives of this city to anter upon the BOILER-COMP boxer 100,000 BTU)SEE FEE SCH. MECHANICAL
abovomentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which
�may in any way accrue gams, s W City in consequeneC of the PERMIT ISSUANCE 10.00 CONST.TAX
! perm( , �,,/�� FOR.CONT. LIG NO. MECH.
''n��'1AR, �,nS TOTAL TOTAL d v
f pphcanl/Con o! t
INSPECTOR COPY