9335 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDINGPROJECT IDENTIFICATION PERMIT NUMBER
9u'LOING APPLICATION & PERMIT 9335
AD ESS
2 MAQ III BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNERS PLAN CHECK VALIDATION
NAMET�- TV. ELECTRIC PERMIT FEE
1 PHONE
NAMEAT s _ UTLETS-SWITCHES-RECEP 10.00/1.00
LIC NO. LIGHTING FIXTURES 10.00/1.00
ADDRESS
PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.N0.
OR
O
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH,
oo ees ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP rTEMP.METER OR POLE INS. 20.00
ADDRESNrs MOTORS SEE FEE SCH.
AoREss
SERVICE CHANGE 20.00
oo LICENSED CONT RACTORS DECLARA'PION TEMP.POLE 30.00
a v I hereby affirm that 1 am licensed under provisions of Chapter 9 7 ISSUANCE DATE
h R vAi (commencing with Section 7000)Of Division 3 Of the Business and BLDG. ELECT. PLG. MECH.
H m z Professions Cod',and my license is in full force and effect. ❑ ❑ ❑ ❑
z D w - License Class Lic.Numhcr
02 r Date Contractor
BUILDING PERMIT
¢ a ¢ OWNER-BUILDER DECLARATION
¢ w u INFORMATION
oA MISC.- REFER TO ORD
X 3 LL m hereby affirm that I ant exempt from 0m Contractor's r License VALUATION $/FT.
H .. o ¢' haw for the following reason.(See 7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
QQQ improve,demolish.or repair any structure,prior to Its Issuance.also ELEC.CONTR. LIC.NO. ELEC. ✓ `�
u requires the applicant for such permit to file a signed statement that C TOTAL PERMITTO
UP u, he is licensed pursuant to the provisions of the Contractor's License 0
r z Law(Chapter 9(commencing with Section 7000)ofDivision 3 of tire
¢ Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE /A/ ,e o
¢ r the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE C13NSTR. `
d ;m_ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of mat more than five hundred dollars(5500)):
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00 OCC.GROUP RES.UNITS
Ihcir sole compensation,will do the work,and the structure is not
intended or offered for supe (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,GOND. 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
• himself re through his own'mred for sale.
provided that such int Drove
measure not throuhh is ornemploforsalrovided that s (hc thudding GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement Is sold within one year of completion,the owner- GAS EASYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did rent build or ire - . RES IND CON PB Other
for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00
Ll 1.as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
Ii,,,Rrd 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 cortractods)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec H.&P.C.fur this WATER HEATER W/VENT 6.00
reason
Owner bate - T1i�. WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DEC[ARATION31bt WATER TREATING EQUIP. 5.00
s I hereby affirm thal l have a certificale of consent to sch-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG,SITE NO.
copy thereof(Seer.3800,Lab..).
Policy No. Company
O ❑ Certified copy is hereby furnished FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with the-city-inxpcetlon^division-
O Applicant MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N❑
= y CFR1'IFICATF,OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.0 C.
W > COMPENSATIONINSURANCF PIED.CONTH. LIC.NO. PLG.
0- Z 1'I'his' Section need not be completed if 0m permit is run ane TOTAL Y❑ N[] Y[:] ❑
N
hundred d011ms(51001 or less.)
U O I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H Hnit is issued,I shall not employ any person in any manner so as to
U W become subject to the Workers'Compensation Laws of California.
a Dale Applicant ALTER OR ADD TO MECH. 5.00 BUILDING / 4?_0
>_ W NOTICE TO APPLICANT: It,after making this Certificate of Ex-
F Z creation,you should became subject to she Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10MCF.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10)"C.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that them is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the 3097 iC'o C ante of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name
HEATING UNIT(OV ER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify ilial l 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
ordinances and state laws relating to building construction, and 80ILER-COMP(3H.P.or100,000B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 STU)SEE FEE SCH. MECHANICAL
ahuvc-menlioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against fiabillties,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
gating of this permit, MECH.CONT. LIC.NO. MECH,
A
TOTAL TOTAL 4�
/Signa reo Applicant/Contractor U e
.INSPECTOR COPY ,