9436APPLICANT TO FILL IN INFORMATIONWITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT I DENT( FICATION
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
9436
BUILDING
ADDRESS r
U U 4GI GS gd
OWNER'S
NAME
CITY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
MTdHONE
NAMERA oRs
UTLETS -SWITCHES-RECEP 10.00/1.00
Q LIC, No.
L IGHTI NG FIXTU RES 10.00/1.00
cDNrRAcro U....pae (�
ADDRESS
C
APPLIANCES - RESIDENTIAL 4.00
1PANELS 16.06
Q Vw PHDNE 7
DATE OF APPLICATION
ARCHITECT ,
OR
PANELS (OVER 200 AMP) 26,66
PLANCHECKFEE P.C.NO.
ENGINEER
LIC, NO.
SIGNS TRANS. 3.00
ADDRESS ENG'
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00
ZIP
APPLICANT '$
AooeeADDRESSSERVICE
MOTORS SEE FEE SCH.
CHANGE 20.00
LICENSED CON 'I'RAC'Tons DECLARA'T'ION
TEMP, POLE 30.00
I hereby at that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, anq my license is in full force f
License Cl_ LF _ Numbe�
ISSUANCE DATE
BLDG.
❑
ELECT.
❑
I PLG. MECH,
❑
Date Convac[or
Contractor
BUILDING PERMIT
INFORMATION
OWNER -BUILDER DECLARATION
1 hereby allina that I am exempt from the Contractor's Liccns°
Law for the following reason.(Sec. 7031.5. Busmrssand Professions
Code: Any city or county which requires a permit to construct, alter,
MISC.- REFER TO ORD
PERMIT ISSUANCE 10.00
VALUATION
$/FT.
ELEC. CONTR. LIC. NO.
ELEC.
TOTAL
improve, demolish, or repair any structure, prior to its issuance. also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9 (commencing with Section 7000) of F ivision 3 of the
Business and Profe.um, Code) or that he is exempt therefrom and
PERMIT TO
OTY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
the basis ar thealleged exemption. Any violation of Seclion7031.5
by any applicant for a permit subjects the applicant ton civil penalty
of not mom than five hundred dollars (S500). 1:
ALTER -DRAIN -WATER IEA.15.00
❑ I , as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA,COND. 5.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Con tl.C[or S Licrnsc law does not apply to an owner of
FIXTURES - PER TRAP 5.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
mentsurenolintendedoroffered for sole. It, however, the building
GAS-EA.SYSTEM-I1NC.40UTLETS 6.00
or improvement is sold within one year of completion, the owner.
builder will have the burden of proving that h e did not build or ice-
prove for purpose of sale.).INDUSTRIAL
❑ 1, as owner of the property, am exclusively contracting with
GAS EASYSTEM OVER 4 IEA) 200
- . -..
BUILDING USE
REs IND CON PS Other
❑ O ❑ 1:1 El
WASTE INTER3000
- . .
licensed contractors to construct the project (Sec 7044, Business
and Professions Code: The Contractor's License Law does not apply
to an owner of property collo huilds or improves thereon, and who
" LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
'
ASSESSORS PARCEL NO.
'
LAWN SPRINKLERS - OVER 5 (EA,) 1.00
contracts I'or such projects with a contmcloAs) licensed pursuant to
the Contractor s License Law.
SEWER. -SANITARY -STORM EA. 20011 1
/ 0.00
TRACT NO,
PARCEL NO,
❑ lam exempt under Sec... B,&P,C, for this
reason
WATEh HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
WORKERS'COMPGNSATION DECLARAI]ON
I hereby AErn that I have a certificate of consent to se B -insure.
or a certificate of Workers' Compensation Insurance, or a certified
T�
ZONING
ENG. SITE NO.
copy thereof (Sec. 3800, Lab. C.)
Policy No. Company
�CerliOedcopy is hereby furnished-
ertified co is fli0 the `�Iy inspcUion division
ppGcwv`�S,gNrnn:
a
MISC.- - REFER TO ORD.
FIRE SPR INK
YE] N�
ENERGY T-24
YF] N�
CER'l IFICATE of Ii XIiMPI '[ON FROM WORKERS' 1.
PERMIT. ISSUANCE 10.00 g ik
FLOOD ZONE
A. L.u.c.
COM1IPIiNSmATION' INSURANCE' `PLG.
(This section need not he cnpleted if the permit is for one
v� N�
v� N�
CONTR. LIC. NO.
PLG. Qt
TOTAL
hundred dottars(S 10(1 or less.)
I certify that in the performance of the work for which this per.
mit is issued, I shall not employ any person in any manner so as to
DTV. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
'
become subject to the Workers' Compensation Laws of California.
Date Applicant
NOTICE '1'O APPLICANT'. It, alter making this Certificate of fix
ALTER OR ADD TO MECH. 5.00
APPLIANCE 5.00
PLAN CHECK
FEE'
emption, you slmuld become subject to the Worker' Compensation
Provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall federated revoked.
AIR HANDLING UNIT (TO 10=C.F.M,) 4.00
AIR HANDLING UNIT (OVER 10MC.EM.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a comovetion lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
-
the performance of the work bar which this permit is issued (Sue.
3097, Cie C.).
'Lender's
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Name
Lender's Name
HEATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
VENTILATION FAN (SINGLE) 4,00
%tI certify that I have read this application and stale that the above
information is correct. I agree to comply with all city and county
ordinances and stale laws relating to building ""'st etion, and
PLUMBING
oa i
BOILER- COMM H.P. Or 100,000 B.T.U.) 6.00
BOILER -COMP lover 100,000 BTU( SEE FEE SCH.
MECHANICAL
hereby enthoed roprrty for insve, ec this rp es cntcr anon the
above-mrntloned properly for inspection purposes.
(We) agree tD save, indemnify and keep harnlrss the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue against said City in consequence of the
granting of INS permit_
MISC. - REFER TO ORD.
PERMIT ISSUANCE 10.00
CONST. TAX
MECH. CONT. LIC. NO.
MECH.
TOTAL
TOTAL
,I
Slgnatll t'Applicant/Contractor Date
INSPECTOR COPY