9451 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENT[FI CATION PERMIT NUMBER
\, BDILDING 1 APPLICATION & PERMIT
7
ADDRESS III �. BUILDING - ELECTRICAL-PLUMBING-MECHANICAL ,9451
n n u.i a•P q - _
OWNER'S
ryAME PLAN CHECK VALIDATION
QTY. ELECTRIC PERMIT FEE
/,1 t.L..G Li , A'2✓. ,L rI�PHONE
NONERACTons OUTLETS-SWITCHES-RECEP 10.00/1.00
Q I. 1 r n ri. „ 1 T11c.No. LIGHTING FIXTURES 10.00/1.00
ADDRESS
APPLIANCES-RESIDENTIAL 4.00
CONTRACTORS
/'
I I, Ix C11 hI 1,1 n t 1�.T '12 IpI10NE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.No, SIGNS TRANS. 3.00
ADDRESS ENc. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
I /
ZIP EMP.METER OR POLE INS. 20.00 L^y WVI
I
APPLICANT a r MOTORS SEE FEE SCH.
ADDRESS
/n 114 n I[J (I n SERVICE CHANGE 20.00
o o LICKNSED CON"FR ACTORS DECLARATION 1 TEMP.POLE 30.00
G v V 1 hereby affirm that I am licensed under provisions ol' '
Chapter 9 ISSUANCE DA ,E
to i (commencin ith Section 7000)of Division 3 of the Business and
¢ g w BLDG. ELECT. PLG,
MECH.
F y i Professions Code,and my license is in full force and effect. ❑ ❑ ❑
0 oma License Class Lic.Number
Date Co..Inewr
s, r E BUILDING PERMIT
¢ ¢ OWNER-BUILDER DECLARATION
A a a v INFORMATION
X g LL 1 hereby affirm thm 1 am exempt from the Contmetor's License MISC.- REFER TO ORD VALUATION a__O v, Law for file following reason.(Sec.7031.5.Businessand Professions pEflM1T ISSUANCE 10.00 S/FT.
Code:Any city or county which requires a permit to construct,alter, 3
c 2improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC. / b
u au- G LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
$ he is licensed pursuant to the provisions of the Contractor's License ^�
Hzi Law(Chapter 9(commencing wit),Section 7000)of Division 3 ofthc 1� �•
i o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE .J�/tsl0 /f J fI.,
¢ I- o the basis for the alleged exemption.Any violas ion of Scel ion 7031.5 STORIES TYPE CONSTR.
Li ; '9 by any applicant for a permit Subjects the applicant too Civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollar,(S500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole comtr
pensation,will do the work,and the sucture is not
.intended or offered for sale (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,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
himselfor through his own employees,provided that such improve-
inentsarenotintendedorofferedl'or sale.if,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the mwncr- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Ome.
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
)& I,as owner of the property,con exclusively contracting with E] 0 El El El
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 Conm
trazr'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 contractorts)licensed pu Ramon to
the Commetur's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO, PARCEL NO.
❑ I am exempt ander Sri. ,B.&P.C.for O
reason 4lis WATER HEATER W/VENT 6.00
I I _ 1 ¢ , " A
Owner ✓ "' '^"' "' '' Date s Imo' r WATER SYSTEM 5.00 IL
1i ala : x ACC.DATE ACC.FE NO.
WO RKERS'COMPENSA'I'ION DE LARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a ctnil'Icd ZONING ENG.SITE NO.
copy thereof(Sea.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby'furnished. FIRE SPRINK ENERGY T"24
wZ Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant y ❑ IN v NO
~ rn PERMIT ISSUANCE 10.00
LU CE RTIFICATEOFEXF.ION IONFROb1WORK IiRS' FLOOD ZONE A.L.U.C.
W need not be completed
INSURA NCI: PLG.CONTE. uC.NO. PLG,
D Z hundIT red
section need not be completed if the permit is for one I TOTAL
hundred dollars(5100)or less) '
U O I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued, 1 sha11 not employ uny person in any Ino n mer o as to
O U become subject to the Workers'Compensation Laws of California.
Date-Appliclunt BUILDING 21( a
>_ N NOTICE TO APPLICANT: If,after making this Certificate of Bx- ALTER OR ADD TO MECH. 5.00 ..7d,
2 emptiwr,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.N0 4.00
CONSTRUCFION LIiND1NG AGENCY AIR HANDLING UNIT(OVER 10A00QF.M.) 6.00 SEISMIC FEE S�
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,Civ.CJ. H EATING UN IT(TO 100,000 B.T.U.) 8.00
Lenders Name H EATI N G U N IT(OV E R 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
• ordinances ^s correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B,T.U.) 6.00 PLUMBING
ordinances and state laws relating to building city
and co any
hereby authorize representatives of this city to enter upon fire BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harnlem the City of MISC.- REFER TO ORD.
Cupertino againsl�"it"lilies,judgments, costs and expenses which CONST.TAX
may ti o aa)vay aceruyagairtst sant :4;in consequence of the PERMIT ISSUANCE 10.00
gran ABN f�Aks permr[' I' MECH.CONT. LIC.NO. MECN.
•y \ �_ TOTAL TOTAL
iithi re'ofA pplicant/Cont- tray-off t- Date -�
INSPECTOR COPY