C9355 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
- - PERMIT NUMBER
BUILDING PROJECT IDENTIFICATION
BUILDING
APPLICATION & PERMIT
PDDRENS
0 r, BUILDING-ELECTRICAL-PLUMBING -MECHANICA 9355
OWNERLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
��•' �J/ /�f�
CONTR LT fl'$ PHONE K
NAME UTLETS•-SWITCHES-RECEP 10.00/1.00
rvG.3 LIGHTING FIXTURES 10.00/1.00
C000REss TOR$
APPLIANCES-RESIDENTIAL 4.00
M4 4A PHONE471-OPOPANELS 10.00 DATE OF APPLICATION
onnCHI CT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER '
LIC.No. SIGNS TRANS. 3.00
ARCHeOR ENO. SPECIAL CIRCUIT S.QQ PERMIT VALIDATION
ADDRzIP TEMP.METER OR POLE INS. 20.00
APPLICANT$ MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 ('
o o LICENSED CONT RAcfORS DBCLA RATION TEMP.POLE 30.00
¢ WU v I hereby of firm that I am lice.sed under provisions of Chapter 9 ISSUANCE DATE
04 w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H 7 z 1'mfersions Code,and my license is in full fur<r unJ effe t.
0 O v - License Class, -1 f;,._Lic.Number 16, D
o w F u, Date Contractor
ay � � 5�- CC UG(m4 yC BUILDING PERMIT
¢ ¢ 4 ER-BUILDER DECLARATION
0 n o INFORMATION
w ;A, y I hereby affirm that I am exempt front the Contractor's License MISC.- REFER TO ORD
LL04 Law for the following reason.(Sec.703 I.S.Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
w f Code:Anycityorcou_nty which requimsa peril mconstmeLaller, /"(, 7V
p p' y prior to its issuance,also ELEG CONTR. LIC.NO. .1 /
¢ re 4 o improve,demolish,or repair an structure,pre ELEC. ,
rc W m 2 requires the applicant for Such pernin t0 file signed statement that TOTAL 1\J PERMIT T
he is licensed pursuant to the provisions of the Contractor0
Contractor's License
Hit
Law(Chapter9(commencing with Section 7000)of Division 3 of t he
i o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ H o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
so
d ; m by any applicant for a permit subjects the applicant ton civil penally
of not more than five hundred dollars(S500).): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (SP,. 7044, Buslncss and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractors 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
•
himselforof ughrote de ownemployees,for sale ILhoded ever.the
improve- GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
mems are not intended orthin Ton for sale.IL however the building
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 in,. BUILDING USE
RES IND CON PB OlM1er
prove for purpose ofsule.). INDUSTRIAL WASTE INTER. 30.00
❑ L as owner -,the properly,he oojlns(vSe contracting with
licemcd cum moors to construct the projucl(Sue. 7044,BusinessLAWN SPRINKLERS- 1 INC 5 V.B. 6.(0 - ASSESSORS PARCEL NO.
and Professions Code'(he 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 contractorls)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.2001t/10.00 TRACT NO. PARCEL NO.
❑ tum exmmptunder Sec. ,B.&P.C.forthis WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.GATE ACF FILE NO.
WORK Ii RS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00 / /
I hereby alfirm that I have a certificate cal-consent 10 self-insure, /
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy Ihereof(Sec.3800,Lab,C.).
Policy No./ll, Company
Q ``�� CertIe1 'U copy's hereby lU i+he FIRE SPRINK ENERGY T-24
Z_ Z '�[L.Cnitil'icJ copy is filed with Om CY Ispcctn dwrsmn, MISC.- REFER TO ORD. v 'NQ v N�
O q
~ w '� PERMIT ISSUANCE 10.00
i - CIi RTII'ICATEOF IiXGh1PTIONPROM YORKERS' FLOOD ZONE A.L.U.C.
L COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. y N Y NE]
Z ('this section need not be completed if the permit is for one TOTAL
hundred dollars IS 100)or Its,) _
U O 1 certify that in the perRmnmme of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued, 1 Shull not employ any,Peram in any manner so as In
U hecome su ect t the Workers'COmper IO"I-a f C9fontia.
a Date'ier�(Applicam /�� __• ALTER OR ADD TO MECH. 5.00 BUILDING S fZ
} W NOT( (CANT: if,a t g us er c r f Ex-
2 emPtion,yo 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 s 000
hall be deemed res.ktd. AIR HANDLING UNIT(TO 10, C.F.M.) 4.00
CONSTRUCT ION 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
Lendch Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
'�•`'_ Lender's Address � ELECTRIC
I certify that l have read this application and stale that the ahove VENTILATION FAN (SINGLE) 4.00
• information is correct. I agree to comply with all city and county PLUMBING (J'U
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 /
hereby auOmrize representatives of this city to enter upon the
above mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU(SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of 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
gmnling of This Permit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL db
Signaturf of APPllcant/Contractor
INSPECTOR COPY