8441 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
EmEOINc APPLICATION & PERMIT
ADDRESS 1 y,
j' e � I UI INC - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
•�/ N 441
mE QTV. ELECTRIC PERMIT FEE y..�
PHONE 7,� j� � •�
NAIVEA OUTLETS-SWITCHES-RECEP 10.00/1.00
uc.No. LIGHTING FIXTURES 10.00/1.00 6 `%
CON
TRACTORS PPLIANCES-RESIDENTIAL 4.00 /Q�
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP( 2000 PLANCHECK FEE P.C.NO.
OR .
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
AARCHDDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS. 20.00
APPLICANT s
ADDDRESSDRESSMOTORS SEE FEE SCH. G
SERVICE CHANGE 20.00 7
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 ry`O
u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
o, s,i (commencing with Section,7000)of Division 3 of the Business and¢ BLDG. 'ELECT, PLG. MECH.
H w i Professions Code,and my license is in full force and effect. ❑ ❑ ❑
Z o w - License Class I.R.Number
o O DWc Contractor
a y E BUILDING PERMIT
re ¢ ¢ OWNER-BUILDER DECLARATION
¢ w v INFORMATION
X ;LL m I hereby affirm that I am exempt from the Contractor,License MISC.- REFER TO ORD
FLLy¢ Law for the following reason.f8ec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
Code:Any city or county which requires a permit to construct,aIle,
QQ Q 2 Improve,demolish,Or repair any structure,prior to Its issuance,also ELEC.CONTR. LIC.NO. ELEC.
O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w $ m he is licensed pursuant to the provisions or the Contractor's License
Fir
Law(Chapter 9(commencing with Section 7000)of Div ision 3 of the
¢ Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
it F the basis for the alleged exec rtion.An
g I yviolationo to;I cion orally STORES P STB.
n ; _ by any applicant for a pcnnit subjects the applicant con ith ages as ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than live hundred dollars(8500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
(heir sole compensation,will do the work,and the,facture is not
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 5.00 SO.FT.PLUGR AREA TOTAL ACREAGE
himself or through his own employees,provided that such ouprove-
mentsarenotintendedorofferedforsale.If,howeve,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of cont no
plelion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 ILDwG USE
builder will[race the burden of proving that he did t huild or im-
prove for purpose or sale.). INDUSTRIAL WASTE INTER. 30.00 REs coN pB Omer
I/ Ira,owner o1 the property,am exclusively contracting with ❑ ❑ 1:1l
ice,sell contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:'file Contractor's License Law does not apply
to an owner or property who builds or improves thereon.and who LAWN SPR IN KLERS-OVER 5 (EA.) 1.00 _
contracts for such projects with a contractods)licensed Proment t0 200ft/10.00
the Contracloi s License law. SEWER-SANITARY-STORM EA. 'TRACT NO. PARCEL NO.
❑ I am exempt under Sec,-.BAP.C.for this WATER HEATER W/VENT 6.00
Mason
Ownc s DateWATER SYSTEM - 5.00 ACC.DATE ACC.FILE NO.
X.
WORK ERS'COM PI:N$AT1O5 I)f:CLn(/�'ATIO. WATER TREATING EQUIP. 5.00
1 briefly afore dmf I have a certificate ofam4nl to sclt=insurr.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No. Company '
O ❑ Certified copy is hereby furnished. t
FIRE SPRINK ENERGY T"24
Z 2 E) Certified copy is filed with the city inspection division.
MISC- REFER TO ORD.� O Applicant V❑ No V ❑ N❑
w PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
-- �',- CERTIFICATE PFNiAEION INS PROMN'ORKIiRS'
W'� COh1PIiNSA1'ION INSURANCE PLG.CONTE. LIC NO. PLG
CL Z ('Phis section need tat he completed,if the pcnnit is for one TOTAL Y❑ N❑ Y ❑ N❑
hundred Aollurs (5100)nr lcss.7
U O 1 certify that iu the performance of the work liar which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U. mil is issued,I shall not employ any person in any ni nner so as to
become subject to the Workers'Compuuation Laws of Calil'urnio.
n Date-Applicant ALTER OR ADD TO MECH. 5.00 BUILDING rl
} y y NOTICE TO APPLICANT: If,after making this Certificate of Ex- 7�
2 emption,you sliould become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of tie Labor Code, you must forthwith comply with FEE
CJ 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 I0,000C.F.M.) 6.00 SEISMIC FEE
I 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 pcnnit is issued(Sec. MICROFILM
\ 3097,Civ.C.). H EATING UN IT (TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATI NO UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that 1 have read this application and store fila'"'I'above VENTILATION FAN (SINGLE) 4.00
information is Correct. I agree to comply with all city and mum, PLUMBING
,ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.o-100,000B.T.U.) 6.00
hereby authorize represenmtives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned 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 PERMIT IS 10.00 CONST.TAX
u
my in any way a cerue against said City in w nseq renc r f the
fhming of this permit. MECH.CONT. LIC.NO. MECH.
. I - (N r1 A c^- 7 TOTAL TOTAL
f lufe'oGApplicant/Contracto ) le
IS INSPECTOR COPY