9248 I if
APPLICA T TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
B UI LDING APPLICATION & PERMIT
ADDRESS 9248
O� II 1 r f BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNERS PLAN CHECK VALIDATION
NAME > CITY- ELECTRIC PERMIT FEE
C PRONE Z+'q�
r
NAMERSUTL ETSG-SWITCHES-RECEP 10.00/1.00
LIC.NLIG
O. HTINFIXTURES 10.00/1.00
CONTRACTORS APPLIANCES
PHONE
4.00
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 - PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.No. SIGNS TRANS. 3.00
ADDRESSING SPECIALCIRCUIT 5,00 PERMIT VALIDATION
2,P TEMP.METER OR POLE INS. 20.00
APPLICANTS
ADDRESS MOTORS SEE FEE SCH.
' SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATION TEMP,POLE 30.00
a v u I herehy u1'finn that I am Iiecowd under provlsinns of Chapter 9 ISS CE DATE
(commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
rD z Professions Code,and my license is in full force and effect ❑ ❑ ❑ ❑
Q i w W License Class Lie.Number
F' Date Contractor
- '•
BUILDING PERMIT
rt Q w OWNER-BUILDER DECLARATION INFORMATION
w o a y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u VALUATION $/FT.
E- LL o a Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires o permit to construct,utter,
.re Q.¢ 0 improve,demolish,or repair any structure,prior to its iSauance,also ELEC.CONTR. LIC.NO. ELEC. VV
a- c, requires the applicant for such permit to file a signed statement that TOTAL - PERMIT TO
u w is he is licensed pursuant to Ore provisions or the Contractor's License
r i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe �•-
E E o Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE � SMGL'
CCH the basis for[lie alleged exemption.Any violation of Section 7031.5 STORIES TYPE CON$TR.
La
e- , by any applicant for a permit subjects the applicant too civil penalty ALTER-DRAIN -WATER IEA.) $,00
of nor more than five hundred dollars(5500).):
O I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCGGROUP HES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code=The Contractor's License Law does not apply to an owner of
property who(milds Or improves lheecon,and who does Such work FIXTURES,PER TRAP 5,00 SO,IT,FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
meats are not intended or offered for sale.If.however,the building GAS-EA.SV$TEM-11NC.40UTLETS 6.00
Or improvement is sold withinone year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or int- PES IND CON PS Other
prove for purposefs
oale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec 7044.Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 ASSESSORS PARCEL.NO.
and Professions Code:The Contractor's License Law does not apply
t' to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts hrsueh projects with a mntraemrs)licensed pursuant to 637-14 - 01
�_/4 p
tire ContraclOrS License Law. SEWER-SANITARY-STORM EA.200ft/10.00
TRACT NO. PARCEL NO.
O lura exempt under See. ,B.&I'.C.for this - WATER HEATER W/VENT 6.00
reason
Owner ) N Ume WATER SYSTEM 5.00 ACC.DATE ACG FILE NO,
WORK17RS,COM PI S�TION D 1 C LA RAT 10 N WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofcouseut m self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(See.3800,Lab.C.).
Policy No. Company
O ❑ Certified Copy iS hereby furnished. FIRERPRINK ENERGY T 24
Z Z ❑ Certified copy is filed with Ore city' inspection division. MISC.- REFER TO ORD.
O Applicant Y ❑ N❑ Y ❑ N❑
t~ rn PERMIT ISSUANCE 10.00 PLOOOZONE A.L.Uc.
Lu CIiRTI PICATE OF SA CI EXEMPTION FROM WORKERS'
W COMPfiN$A'I'ION.INSURANCIi PLG.CONTR. LIC.NO. PLG.
Z '(This section need not ti completed if rhe permit is for one TOTAL v❑ NE=LL] Y E] N[]
O hundred dollars(SIOOI or Ices.)
I certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not mnploy any person in any manner so as to
0 O become subject,to the Workers'Compee.sariou Laws of California. '
Ed Date ApplicantALTER OR ADD TO MECH. 5.00 BUILDING
>_ m NO'T'ICE TO APPLICAN F: If,after making this Certificate of lix-
Z_ empti0n,you should become subject is,the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
Provisions of the Labor Code, you mist forthwith comply with FEE
U such provisions or this Permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 101MC.F.M.) 6.00 SEISMIC FEE sa
1 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
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that l have read this application and stare that theabove VENTILATION FAN (SINGLE) 4.00
• in timnatiou is correct. I agree ro comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or100,000B.T.U.) 6.00
hereby authorize representatives of this city t0 cntnr upon the BOILER-COMP (Over 100.000 BTU(SEE FEE SCH. MECHANICAL
above-mentioned property'for inspection purposes.
(WRY agree to save, indemnify and keep harmless the City 0f MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consnluense of the PERMIT ISSUANCE 10.00
granting of this per il. MECH.CONT. LIC.NO..91 P MECH.
TOTAL TOTALuV
XeoT n ontractor ate I Ile
INSPECTOR COPY