9308 (3) APPLICANT TO FILL IN INFORMATION WITHIN REDLINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
60ILDWG APPLICATION & PERMIT
Y ADDRESS 9308
- BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
Ow ER's PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
/ b
PHONE /
.AME ACT Rs UTLETS-SWITCHES-RECEP _1aQO/1.00
LIC,No. LIGHTING FIXTURES 10.00/1.00
CONAC
ADDRESS
PPLIANCES-RESIDENTIAL 4.00
DOss 's
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIc,No. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
].,P rrEMP. METER OR POLE INS. 20.00
APPLICANT'S
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 / q
LICENSED CON"TRACTORS DECLARATION TEMP.POLE 30.00 / //
o o
Q U U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
,HA z w (commencing with Section 7000)of Division 3 of the Business and
¢ H BLDG. ELECT. PLG. MECH.
H ev z Professions Code,and my license is in full force and effect ❑
o i o License Class Lia Number
Date Contractor
a m s4 BUILDING PERMIT
¢ ¢ ¢ OWNER.BUILDER DECLARATION
A o a uINFORMATION
X g LL 1- 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
.. o¢ Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE Sto
VALUATION .$/FT.
Q
Cade:Any city or county which req ulres a permi)to construct,altar,
¢ 6m s- improve,demolish,Or repair an structure,prior to its issuance,also ELEC.CONTR. LIC.NO.
¢ OP' Y ELEC.
m u requires the applicant for such permit to file a signed statement that TOTAL �l PERMIT TO
at he is licensed pursuant to the provisions of the Contractor's License /A/.JTyL
Law(Chapter 9(commencing with Section 7000)of Division 3 of the A
¢ Business and Professions Codd or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
it
¢ 1 F O o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE C
u 3 `0 by any applicant for a permit subjects the applicant to a civil penally _
of not more than five hundred dollar,($500j): ALTER-DRAIN&VENT-WATER (EA.) 500
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sri. 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 44 SO.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees.provided that such improve-
mentsarenotintendedoroffered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or air- BUILDING USE
prove for purposeof sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Orhet
❑ 1,as owner of the property,am exClusively contracting with ❑ ❑ ❑ ❑ ❑
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 Contractor's License Law does nor apply
- to an owner of property who builds or improves thereon,and who LAWN SPR INKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to
the Contractor's License Law. SEWERr-SANITARY-STORM EA.200ft/10.00 t' TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-,IT&P.C.for this WATER HEATER W/VENT 6.00
Ownerreason
/ reason -- Date /- ,. . WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK IiRS'CO IPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure,
m a certificate of Workers Compensalion Insurance,or o cr,tifetl ZONING ENG.SITE NO.
copy thereof(See.3800,Lab.CJ.
Policy No. Company
O ❑ Cenilied copy is herehy furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is filed with the city inspection division. MISC. REFER TO ORD.O Applicant Y ❑ N❑ I Y ❑ 'N❑
~ N PERMIT ISSUANCE
-Lu - CCRTIFICAMPENEAEION INS FROM WORKERS' tO nn �. FLOOD ZONE A.L.U.C. \
W > .COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CLO (This action need not be completed if the permit is for one TOTAL ,\,[0`p Y F] IN Y ❑ ' IN
Z hundred dollurs($100)or less.)
L) O 1 certify That in the pvrl'unnance oftirework 1'or which this per- OTV. MECHANICAL PERMIT FEE FEE SUMMARY !
IL U mit is issued,1 shall not employ any person in any manner"'as to
become subject to tiro Workers'Compe cation Laws of California.
Date Applicant BUILDING
LU
pp ALTER OR ADD TO MECH. 5.00 -S
er} N NO..tioc; 1'O shouldAPPLICAN'1': If,after making this,,'C mpe of ISx-
FZ Orwisin,you tire
Code,
muse Workers Ccomply its APPLIANCE 5.00 PLAN CHECK
provisions io the Labor Code, you nest forthwith comply with 7
' U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000 C.F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
J I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 _
thexnce of the work for which this permit is issued(Sea MICROFILM
3097,,GCivo.anm. HEATING UNIT,ITO 100,000 B.T.U.1 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T-.U.)9.50 ELECTRIC W
I certify that l have read this appllcalion and stow the the above VENTILATION FAN (SINGLE) 4.00 .
•
formation n estate. I agree tog to building with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
orformatio send state lows relating to lywithconstruction, and
hereby authorize representatives of this city,to enter upon the BOILER-COMP(Over 100,000BTU1 SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep hin'less the City or" 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
xxxx granting ofthiS permi, MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL 37
A' Ajrpi aM of rnetor ate
INSPECTOR COPY