The URL can be used to link to this page

9349 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT 1 DENT[FI CATION PERMIT NUMBER DESG APPLICATION & PERMIT AIff7l �� ADDRESS M@ �� BUILDING-ELECTRICAL-PLUMBING -MECHANICAL OWNER'$ PLAN CHECK VALIDATION N - OTY. ELECTRIC PERMIT FEE Q vuoNE07 NAMERAOTORs OUTLETS-SWITCHES-RECEP 10.00/1.00 --L j _ - 14LIC.No. LIGHTING FIXTURES 10.00/1.00 CONTRACTOR'S A C �✓) APPLIANCES-RESIDENTIAL 4.00 ADDRESS e- .r • PHONE 41 f PANELS 10.00 DATE OF APPLICATION ORRCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO. ENGINEER wJ C,V uc.No. SIGNS TRANS. 3.00 AARCHDDRESS ENG. SPECIALCIRCUIT 5,00 PERMIT VALIDATION ZIP 7EMP.METER OR POLE INS. 20.00 ^ AESr$ ADDRDDRESSS MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 / y/ y o o LICENSED COMPRAC'rORS DECLARATION TEMP.POLE 30.00 7// /O ¢ u v .I hereby aft irm that I am licensed under provisions of Chapter 9 ISSUANCE DATE H rt w (Conmuncin,with Section 7000)of Division 3 ol'the Business and BLDG. ELECT. PLG. MECH. H o z Professions Code,and my license is in full force and effect. [:] ❑ ❑ i o A- icense ass !'-"-.Number 9 H D Dace � Contractor Ha ac A N BUILDING PERMIT ¢ m e a OWNL:R-BUILDIiR DECLARATION µ ¢ w U INFORMATION w ;u H 1 hereby affirm that I ani exempt from the Contractor's License MISC.- REFER TO ORD LLoa Law(a,the following reason.(Sec.7031.5,Businrnaul Professions PERMIT ISSUANCE 10.00 VALUATION - y Code:Any city or county which requires a permit to construct.alter, li a, ¢ O improve,demolish,or repair any structure,prior to its issuance,also ELED.CONTH. LIC.NO. ELEC. O n requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO d w m w he is licensed pursuant to the prnvisions of the Contractor's License r z a Law(Chapter 9(commencing with Section 7000)of Division 3 o(the ( i o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE Af e1 ¢ H $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. an a � by any applicant for a permit subjects the applicant to a Civil penally ALTER-DRAIN&VENT-WATER (EA.) 5.00 of not more than five hundred dollars(S500).n ❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEV ICE 4.00 OCC.GROUP REB.UNITS their sole compensation,will do the work,and the structure is not intended or offered for sale(Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00 Code:Time Contractor's License Law does not apply to an owner of property who builds or improves Hereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOT.LACREAGE Dntshimself re of intended his own erred fors Provided thin such improve- mentsarenotintendedoroffored(orsale.lided Hinsuhe building GAS-EA.SYSTEM-11NC.40UTLETS 6.00 or improvcmenl is sold within one year of completion, . . -OVER 4 (EA.) 2.00 the owner- GAS EASYSTEM builder will have the burden of proving that he did not the or inr BUILDING USE prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer ❑ I,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 dues 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 contractor(s)licenwd pursuant to the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO... PARCEL NO. ❑ I um exempt under Sec.-,If&P.C.for this WATER HEATER W/VENT 6.00 reason Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO. WORK ERS'COMPENSAT10N DECLARATION WATER TREATING EQUIP. 5.00 1 hereby affirm that I have a certificate o(consent to self-insure. or a certificate of Workers Compensation Insurance,or a certified ZONING ENG.SITE NO. L copy thereof(See.3800,Lub.C), 9 Policy N..-Com o. Company ti3 Q ❑ crtificd copy is hereby(urnishl v FIRE SPRINK ENERGY--24 z rtified coy is filed wit the city inspection division. MISC.- REFER TO ORD. F p Ap licant p `A V❑ N❑ Y ❑ No CER fICATE OF eXCAI PPION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C. LU COMPENSATION'INSURANCE PLG.CONTR. LIC.NO, PLG. CL Z (This section need not be Completed if the permit is for one TOTAL Y❑ N F] Y❑ N❑ hundmd do l l ors 1$100)or ICs.) U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY LL F mit is issued,I shall not employ any person in any manner so as to O U become subject to the Workers'Compensation Laws of California. d Date ApplicantALTER OR ADD TO MECH. 5.00 BUILDING } m NOTICE TO APPLICANT: If,after making this Certificate of Ex- Z_ emption,you should become subject to the Workers Compensation APPLIANCE 5.00 PLAN CHECK provisions of file Labor Code, you must forthwith comply with FEE U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 4.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.EM.) 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,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 (/1�- Lender' HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 t ELECTRIC Lender's,Add Addrress I certify 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 ooinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 / (w hereby authorize representatives forties of this city to enter upon the BOILER-COMP (Over 100.000 BTU)SEE FEE SCH. MECHANICAL above-mentioned property(orinsp of (h i purposes. QV (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. Cupertino against liabilities,judgments, costs and expenses w 10, PERMIT ISSUANCE 00 hich U(. CONST.TAX may in any way accrue against send City in consequence of the / grflai a ting of fin'licroll MECH.CONT. LIG NO. MECH. S TOTALa CO TOTAL St afureo ppi ant/Commetor ate INSPECTOR COPY I