9430 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
/ BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
�( OORBUILDING APPLICATION & PERMIT
ADDRESS
E55
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 9430
XANF1210 PLAN CHECK VALIDATION
NAME _ OTY. ELECTRIC PERMIT FEE
PHONE
CONTRACTORS dame"crony UTLETS-SWITCHES-RECEP 10.00/1.00
c.NG. C LIGHTING FIXTURES 10.00/1.00
t ADDRESS R crony APPLIANCES-RESIDENTIAL 4.00
Aoo
'HONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMPI 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS END. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. 20.00
ADDRESS MOTORS SEE FEE SCH. /) .
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a u u I hereby attires that I am licensed under provisions of Chapter 9 ISSUANCE DATE
a,< m (<mmnencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H w z Professions Code and my license is in full forte and effect.
z o u - License Chas Lie Number
o m r w Dale-� 3 Contractor-
BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DECLARA NON
o a oINFORMATION
wg ¢ w 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD vA WATION S/FT.
F .a o a Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00
Cade:Any city orcounty whichrequiresapennit to construct,w ELEC.CONTE. LIC.NO.
a a p improve,Demolish,or repair any structure,prior to its issuance,also - ELEC.
a wC n requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
mhe is licensed pursuant to the provisions of tile Contractor's License
F z i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe I,
- a Nosiness and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE l%4F�
¢ 171
o the basis for the alleged exemption.Any violation of$ection 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(8500).):
O I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCG GROUP RES.UNITS
(licit wile compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,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.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees.provided that such improve-
.encs are not intended or offered for sales It,however,the budding GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ I,as 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.
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 contruetnr(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ 1 all exempt under Sec. ,B.&P.C.Ru this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACD.FILE NO.
WORKERS'COMPENSAT ION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self insure,/ ZONING ENG.SITE NO.Or a certificate of Workers'Compensation Insurance.or a cerlifed
copy thereof(Sec.3800,Lab C.). �y
Policy No. Company -�b,Cr/r/y0
O 13 Cetlif ted copy is hereby fined FIRE SPRINK ENERGY T 24
Z_ Z ��``Cenifeytis filed with the city inspection division. MISC.- REFER TO ORD.
A;*icant Y❑ N❑ Y ❑ N❑
~ rn PERMIT ISSUANCE 10.00
� - GIiRTIFICATEOI'IiXEh1PTION FROM WORKERS' FLOOD ZONE A.L.u.O.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O 1'1'his section need not be completed if the permit is for one TOTAL v❑ N E] Y❑ NE]
Z hundred dollars IS 100)or less)
U O I certify that in the performance of the work tor which anis per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL I- Bill is issued,I shall not employ any parson in any manner so as to
O L) become subject to the Workers'Compensalion Laws of California BUILDING
res Dam Applicant ALTER OR ADD TO MECH. 5.00
} to NOTICE TO APPLICANT: If,after making fills Certificate of
Ex-emption.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.EM.) 6.00 SEISMIC FEE
Ihereby 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
y 3097,Cie,CJ. HEATINGrUN1T(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's NamAddress HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Icertify that l have read this application.And state[flat the above VENTILATION.FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
oninan.s and state laws relating to budding construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.001 -
hercby authorize representatives of this city to aver upon the BOILER-COMP(Over100,o00BTU)SEEFEESCH. 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 ISSUANCE 10.00 CONST.TAX
may in any way accrue against,said City in consequence of the /r1
2 graining of this permit, MECH.CONT. LIC.NO. MECH.
/� TOTAL a �, TOTAL
&gnaturE o^fApp�I dnF/ Da[F'
INSPECTOR COPY