C9517 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION ERMITNUMBER
'
BUILDING APPLICATION & PERMIT
A//2 .2G BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 9517
PLAN CHECK VALIDATION
- NAME I G CITY. ELECTRIC PERMIT FEE
�'• V • /tf. 1U1
I S J FNpRDNE
CONTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
tic.pz,%o •JQT+ LIGHTI NG FIXTURES 10.00/1.00
aooREs
CONTRA DR's PPLIANCES-RESIDENTIAL 4.00
(, FXOtE� V PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
E EE
uc. i SIGNS TRANS. 3.00 {
aDDRES eNa SPECIAL CIRCUIT $.QQ PERMIT VALIDATION )
ZIP TEMP.METER OR POLE INS. 20.00 /n
APPLICANTS �' MOTORS SEE FEE SCH. U.P'.(�A'p.'ti/
ADD $
SERVICE CHANGE 20.00
w o 2 LICENSED CON'T'RACTORS DECLARATION TEMP.POLE 30.00 /e i
a i w 1 hereby affirm that I am licensed under provisions ofChapter a 9 ISSUANCE DATE
(commenting with Section 7000)of Division 3 of the Business and �, B D ELEC P MEC .
- H w Z Professions Colk'1 license is in full fq}Pad effed�
z o m- License Clu s t Li c.NoinIr cy((�
om� w Date Comr r
a L f w BUILDING PERMIT'
II: ¢ a OWN:R-BUILDER DEC ARA' I
E o s u INFORMATION
w LL I- I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
LL_ oin Law for the following reason, 7031.5.Businessand Professions pERMIT ISSUANCE 10.00 VALUATION $/FT.
5 Code:Any city or county which requires a permit to construct,alter,
QQ 4 0O improve,demolish,or repair structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
LL requires till'applicant for such permit t0 file it signed statericat that � TOTAL '' pERMIT TO
n w m a he is licensed pursuant to the provisions of the Contractor's License
H z t- Law(Chapter 9(commencingw'ith Section 70001of Division 3 of the
D Business and Professions Code)or that he is exempt therefrom and ATV. PLUMBING PERMIT FEE
Ie I- p the basis for the alleged exemption.Any violation of Section 7031.5 -STORIES PE CONSTR.
n ; m 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(SSOOL):
❑ I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES:UNITS
their sole compensation,will do Ilse work,and the structure is not
intended or offered for sale (Sec. 7044, Busitmss and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractor's License Law does riot apply to an owner of
property who builds or improves thereon.and who does such work FIXTURES-PER TRAP 5.00 50,FT.FLOOR AREA TOTAL ACREAGE
-• himself or throughTis 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 com Pletiomehe owner /
builder will have the burden of proving that he did not build or int- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE/
Prov,for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 R IND CON Bmer
B O
❑ I,as owner of the property,am exclusively contracting with 1 ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORSPARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contmctoos)licensed pursuant la
the Contractors License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I um exempt under Sec.-,ll&P.C.for Blis WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC,DATE ACC.FILE NO.
wORKERS'COMPENSAT1ON DECLARATION WATER TREATING EQUIP. 5.00
I hereby ffn. that 1 have a certificate of consent to selhinsure,
or a certificate of Workers'Compensation Insure e ,or a cert ificd ZONING ENG.SITE NO.
copy thereof(See 3800,Lab.C.). �J/y37 i7l
Policy No.- Company
Q ❑ Cerlifie co yrs hereby undi�dJ�d. L FIRE SPRINK ENERGY T 24
Z Z �}Cerli y' f1•.I.will�/,*t to cit spection division.
0 Applicant Y/1i„�3 ' MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
CC 5 �,� PERMIT ISSUANCE 10.00
- !r CIi RTI IG1TE OF IS%Ch1 PPION FROM WORKERS' FLooD zOrvE A.L.u.c.
LU - COMPFNSATION I INSURANCE PLG.CONTR. LIC.NO. PLG. IQU.
CL 0CL Z (This' s,,Iio. need not he completed if the permit is Iiln one TATA / Y❑ N❑. Y ❑ N❑
hundred dollars(S 1001 or Icss.)
U 0 I certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is ict ed,I shall not employ an person in any m der so to \
O w in' I bje to th Worker 'o en oml:aws alit ia.
Date �pplican • ALTER OR ADD TO MECH. 5.00 BUILDING 4.UgO
} m NOTI I! i ICAN'I'. ter mu tI I us C n Main of rix- `T V
F-. ? cmpUon,you slwuld hecomes eject to the Workers'Conners
APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must torthwitll comply with
U such provisions or this permit shall be deemed ,,mkld. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction Iendin agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of thework �7r which tIy'I,permit ' Issued(See MICROFILM
30ndcr', .am /),•- / /J HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name G11t11e1'L
Lenders address HEATI NG UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I cerlily that I have 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 pp U
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorise representatives of this city to enter upon lire BOILER-COMP (Over l0Qoo0 BTU)SEE FEE SCH. MECHANICAL ! /�
above-mentioned properly for inspection purpose,.
(We) agree to save, indemnify and keep handless the City of MISC.,- REFER TO ORD. _
Cupertino against liabilities.JJJJudgments,`costs and penses which PE
ISSUANCE 10.00 CONST.TAX
may an w accTe [ s- Cily i - qu cc of the
gr o IT /l MECH.CONT. LIG NO. MECH.
4 TOTAL U0 TOTAL qo
Signaturo tic yu for I ate �-
INSPECTOR COPY - -