C9444 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION ERMIT NUMBER
gO,Lp,NG APPLICATION & PERMIT 8444
X AODR E55
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
NAMERS ( PLAN CHECK VALIDATION
N 'P\(I�1 `T- '7 TV. ELECTRIC PERMIT FEE
`O PHONE G
CONTRACTORS GUTLETS-SWITCHES-RECEP 10.00/1.00
h LIC.NO. LIGHTING FIXTURES 10.00/1.00
coDT AG R.ADDRESS 'sQz APPLIANCES-RESIDENTIAL 4.00
ZZ. CO VV)A42.Y T PHONE 3�l/ PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
ENGINE R
Sec.No. SIGNS TRANS. 3.00
aooae R SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
zIv EMP.METER OR POLE INS. 20.00
AvvucaNr MOTORS 1 SEE FEE SCH. /lJ•,"`.'e��'�
ADORE
ss
- SERVICE CHANGE 20.00 t (/
w o o LICENSED CONIRACTORS DECLAUTION TEMP.POLE 30.00
a v I hereby all inn that 1 am licensed under provisions of Chapter 9 i ISSUANCE DATE •/
(commencing with Section 7000)of Division 3 of the Business and
¢ vAi / BLDG. ELECT. PLG. MECH.
N,z Professions Co dc,and my license is in full force and eRcul. 4,/L7 y�, p U v ❑ ❑ ❑ ❑
0 o m License Class Lic.Number
o m t 0>/
/ [)ate 19 gr KC4Contractor
a Y f BUILDING PERMIT
¢ tc a OWNER-BUILDER DECLARATION INFORMATION
X y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
F .. o a Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00 Ta VALUATION $/FT. ;
Code:Any city orcounty whiellre,mmsapennitto const ict,alter, '�ir(_1/'�/) `
aa Q Q improve,demolish,or ropair any structure,prior to its issuance,also ELEC.CONTR. 'pl LIC.NO. ELEC.
u ¢ requires the applicant for such permit to file a Signed statement that TOTAL PERMIT TO
he is licensed pursuant to the provisions ol'the Contractor's License /
H z i Law(Chapter9(commencing with Section 7000)of Division 3 ofthe
z o Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
Ic m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTq.�
a ; _ by any applicant for a Permit subjects tine applicant toacivil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00 /� �
of not more than five hundred dollar,($500).) QV•Vr jL;�
❑ 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 lire structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code: The Contractor's License Law docs not apply to an owner of
Property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5,00 ' SO.FT.FLOOD AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedoroffeud for sale.If,however.the building GAS-EA.S)ITEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS EASYSTEM OVER 4(EA.) 200 BUILDING USE
builder will have the burden of proving that h - . - . .
e did not build or ire- RES IND CDN PB Omer
Prove for purpose of sale,). INDUSTRIAL WASTE INTER. 30.00
❑ 1,as owner of the property,um exclusively contracting with ❑ c3 ❑ ❑ o
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B 6.00 ASSESSORS PARCEL NO. ,
and Professions Cole:The Contractor's License Law docs not apply
In an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
tr
conacts for such projects with a contractor(s)licenttd pursuant to
theContractor's License Law. SEWER-SANITARY-STORMEA.2 ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec,-,B.&P.C.for this WATER HEATER W/VENT 6.00
reason T
OWpp1 ])life WATER SYSTEM 5.00
s ACC.DATE ACC.FILE NO.
WORK Ii RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have acertificate ofconsent 10Sel Giusure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance or a egnified
copy thereof lsec.3800 Ik"Ve f_�
Popsy er Cu ICJJ
0 ❑ Cerci and copTl,;h reby furnished.
z Z ❑ Ce'
d 'opy is tiled with the insfRL'tibR'JMiSioB. FIRE SPR INK ENERGY T14
F _ ` MISC.- REFER TO ORD.
OY� Applicant V N v N
ir D CFR('IF-ICATE 017 EXEMPTION I7ROM WORKERS' PERMIT ISSUANCE 10.00 FFjLOODZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. T"
Q. Z (This Section need not be completed if the permit is for one TOTAL e- ti [3Y NE] Y NC]
hundred dollars(S 100)or less.) 1
U 0 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mil is issued, I shall not employ any person in any manner so as to I
OU become subject to the Workers Conmemution Laws o(Caliti rria.
Do
0- Date Applicant BUILDING p�a
} to NOTICE: TO APPLICANT'. If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00 Q
F Z_ emption,you should become subject to the Workers Compensation APPLIANCE5.0 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE .
5 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M-) 4.0
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 permit is issued(Sec. MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.)"w8.00
Lender's Name
Addr, HEATING UNIT(OVER 100,000 B.T.U.0.50
Lender's Address - ELECTRIC oZ��
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE)' 4.00
S information is correct. I agree to comply with all city and county PLUMBING p4l
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 2
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000BTU)SEE FEE SCH. MECHANICAL
above-mentioned property forinspection purposes.
(We) agree to save, indemnify and keep harmless 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 corpeepapece of the PERMIT ISSUANCE 10.00
grantingofthis permit MECH.CONT. LIC.NO. MECH.
0 ' IXL
TOTAL TOTAL /b �
igna f I - •I )afT
INSPECTOR COPY