C9428 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT , 8428
ADDRESS BUILDING-ELECTRICAL-PLUMBING-MECHANICAL `/
O qp PLAN CHECK VALIDATION
.NAME L /♦ OTY. ELECTRIC PERMIT FEE L
N E TDPs UTLETS-SWITCHES-RECEP 10.00/1.00 'rL_5`L ✓� /�S
.No. - LIGHTING FIXTURES 10.00/1.00 '7 0
r I CONT A ORs PPLIANCES-RESIDENTIAL 4.00 r.
ADDRESS
a3 :, 03f6
PANELS 10.00 DATE OF APPLICATION
ARC IT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.N0.
OR
I ENGINEER
uc.No. SIGNS TRANS. 3.00 t
I
ADDRESS ENG SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
l
ZIP FrEMP.METER OR POLE INS. 20.00 ,
APPLICANTS
ADDRESS MOTORS SEE FEE SCH.
-
SERVICE CHANGE 20.00
"F+o o LICENSED CONTTEMP.POLE 30.00RACTORS DECLARATION f,/���1S
a u I hereby affirm that I am licensed under prm'isions o(Chaptcr9 ISSUANC&D
a a (commencing with Section 7000)of Division 3 of the Business andT BLDG. ELECT. PLG. MECH.
H w z Professions Code,and my license is in full force and effect.
z 0 w- License Class I Number
0 m -to CO. act
H //�
¢ m rc a ER-BUILDER DEC A' WA
E/ r BUI NG IT
a a, u INFORMATION
X ; LL m 1 hereby affirm that I am exempt from the C MISC.- flEFER TO ORD
u 0 ¢ Law for the following reason.(Sec.7031.5,Business an ro esvions PERMIT ISSUANCE 10.00 VALUATION $/FT.
Code:Any city orcounty which requires a permit to co strucLalteq
I- or to its issuance,also ELEC.DONTR. LIC.NO.
a ¢ ¢ 0 improve,demolish,or repair any structure,prior ELEG.
0 u requires the applicant I'or such permit to file a signed stutenam that TOTAL t MIT TO
n w m W he is licensed pursuant to the provisions of the Contractoh License
F z r Law(Chapler9(commencingwi(h Seclion7000)of Division3ofthc
¢ Business and Professions Code)or that lie is exempt therefrom and QTY. PLUMBING PERMIT FEE
or r o the basis for the alleged exemption.Any violation of Section 7031.5 P TR.
a $T by any applicant for a permit subjects lire applicant to a civil penalty ALTER-DRAIN -WATER IEA`) 5.00 ,
of not more than five hundred dollars(5500).1:
❑ I,as owner of the property,or my employeeswith wages as BACK FLOW PROTECT. DEVICE - 4.00 O v RES.UNITS
their sole compensation,will do the work,and the structure 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 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.FLOOR AREA TOTALACREAGE
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-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner-
,builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
-' prove for purpose of sale.). INDUSTRIAL WASTE INTER3000 RES IND CON PB Other
❑ 1,as owner of the property,am exclusively contracting with . . ElEl ❑ Q
licensed contractors to constnmt the project(Sec. 7044,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 1 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 eontractons)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO, PARCEL NO.
❑ 1 um exempt under Sec. ,B.&P.C.for this
WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
' 1 hereby affirm that 1 have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
/ ropy ihcrcof(Scc. 3800,Lah.CJ. ,
T Policy No.rt is he cb yi hFar`tgg��./i11G
Q ❑ Certified copy is hereby( [V� FIRESPRINK ENERGY T-24
Z Z ❑-Caro Mid i ed wstn thllJ�d✓AQ2QZd1dl' inn.
F- Oj ApPli<a _ ` MISC.- REFER 70 ORD. Y ❑ N� Y N�
MN CHR'I'1FICA*1';OF I CINP1 )<PR 1 ;RS PERMIT ISSUANCE 10.00 FLOOD ZONE aL.0 c.
LU > CONIPENSATION INSURANCE L, PLG.CONTR. LIC.NO. PLG.
CL 0 (This section needriot be completed if the permit is for one TOTAL
Z hundred dollms IS 100)or Icss,)
U O 1 c,Hi y�thiit in the perfomance of tire work farwhich this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
1 LL I-.. mit is.issued,I shall not employ any person in any manner so as to
U,t' become subject to the Workers'Compensation Laws of California.
so, W� I Date
Applicant BUILDING
Do pP ALTER OR ADD TO MECH. 5.00
.�'a,};Z s NO'FR0ii'I'O API'LICANT: If,after making this Certificate of Ex-
_ emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provRions.of the Labor Code. you most forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=1 .F.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNITIOVER I0,0WC.F.M.) 6.00 SEISMIC FEE .
1 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.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name H EATI NG UNIT(OVER 100,000 B.T.U.)9.50 17
V Lenders Address ELECTRIC
I certify that 1 hove read this application and state that the above VENTILATION FAN (SINGLE) 4.00
.� information is correct. I agree to comply;with all city and county PLUMBING L9
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city; to enter upon the BOILER-COMP Inver IDQ000 BTU)SEE FEE SCH. MECHANICAL
e
abovmentioned property for inspection ,muss.
(We) agree to save, mccnmify and keep hanolcsS Tire City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses wnich PERMIT ISSUANCE1000 CONST.TAX
accrue any way against 6 City in consequence o the .
gr f g f tis Permit. MECH.CONT. LIC.NO. MECH. ww
e ' TorAL TOTAL I�
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