9409 APPLICANT TO FILL IN INFORMATIONWITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT /�
ADDRESS _ 9409 4 o�y
� V BUILDING - ELECTRICAL-PLUMBING-MECHANICAL y J
O NER'S -- PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
' PHONE -
NAME cT � UTLETS-SWITCHES-RECEP 10.00/1.00
uc.rvo. LIGHTING FIXTURES 10.00/1.00 4-a
A -
DDREAC7oes APPLIANCES-RESIDENTIAL 4.00
ADDRESS )ip lyaw4l)
PHONEZ44 PANELS 10.00 DATE OF APPLICATION
ORCNI EC �R.�yL`
PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER te'"•"'�� LIC.NO. SIGNS TRANS. 3.00
ADDREss END. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
zIPrrEMP.METER OR POLE INS. 20.00 n
ADDREss
AHOArvr'S MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
uF+¢0 o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a u La 1 hereby afl'IRn that 1 am hernsed under provisions of Chapter,9 ISSUANCE OATS
au (commencing with Suction 7000)of Division 3 Of the Business and BLDG. ELECT. PLG. MECH.
zi z Professions Code.and my license is in full Rnce and effect.
z O wt - License Class Lid Number
0 w Dalc 4 Contmd r
a a, f , BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DECL A'fION
¢ u, U = INFORMATION
w o A,H 1 hereby affirm that I am exempt from file Contractor's License MISC.; REFER TO ORD.'
if:
u VALUATION $/FT.
F _ m a Law for the following reason(Sec.7031.5,Business and Professions PERMIt ISSUANCE tOAD, �/
Code:Any cilyorcounty which requires a permit to conswcd.alter,
ELEC.CONTR. LIC.NO.
¢ a 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.
O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
A w
As he is licensed pursuant to the provisions of file Connactor's License r T
H z i
Law(Chapter 9(commencing with Section 7000)o f Division 3o Rhe G L/
i o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a _ by any opplicunt for a permit subjects the.mplicunlloBcivilpenalty ALTER-DRAIN&VENT-WATER IEA.) 5.00
of not more than five hundred dollars($500t):
❑ 1,as owner of the propert,or my mnploye"s with wages as BACK F LOW PROTECT. DEV ICE 4.00 OCC,GROUP RES.UNITS
their sole compensation,will do the wink,Ad Ole 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
properly 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-
mends are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, - . -OVER 4 IEA.) 2.00 the owner- GAS EASYSTEM
builder will have the burden of proving that he did not build or int BUILDING USE
prove for purpose ofsale). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ I,as owner of the properly',am exclusively contracting with ❑ ❑ ❑ ❑ ;❑
licensed Contractors to construct file 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 IEA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant m SEWER-SANITARY-STORM EA.200ft 10.00
the Contractors License Law, / TRACT NO. PARCEL NO.
O lam uxcmpt under Sec. ,B&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACG FILE NO.
WORK ERS'COMPENSA'I'ION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ul COnscat to self-mune' ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy thercof(Scc.3800,Lab.C.).
Policy Non.a 9.11wompany {��'M F-
• O _ IQ,
Cerldl'en opy is hereby furnished. FIRE SHRINK ENERGY T 24
Z_ Z IQCertified copy is filed with the City inspection division. MISC.- REFER TO ORD.
O x Applicant , Y ❑ N❑ Y ❑ N❑
~ va/ PERMIT,ISSUANCE 10.00
� Cl:- �I ICATG OF F,XfiMYIT(yN PROM WORKIi RS' FLOOD ZONE A.LUC.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
n' O (This section need not be completed if flo, permit is for one TOTAL v E:] N❑ Y [D NE]
Z hundred dollur05100)or less.)
U O I certify that in the perl'onnaice of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL E- mil is issued,I shall not employ any person in any manner so as to
O w beconn subject to the Workers'Compeasm ion Laws of California.
LU Data Applicant BUILDING
} N NOTICE: 'f0 APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
F Z emption,you should become subject to the Workers'Compensation APPLIANCE 1 5.00 PLAN CHECK
provision of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10000C.F.M.) 4.00
CONSTRUCT'ION 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,CN.C.). "'+. H EATI NG UN IT(TO 100,000 B.T.U.) 8.00
Lenders Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I c,,I,fy that I have read this application and state Had the above VENTILATION FAN (SINGLE) 4.00
irdinim correct I agree to comply with all city cti county PLUMBING
ordinances
and state laws relating building construction, and BOILER-COMP(3 H.P.or 100,0008.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above mentioned property for inspection purposes. BOILER-COMP (Over 100.000 BTU)SEE FEE SCH. MECHANICAL
• (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
granting of this permit MECH.CONT. LIQ NO. MECH.
�,.y� t TOTAL TOTAL
[rgrt�f o`A and/C'ontrac�br $/ Danek
INSPECTOR COPY