9400 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
I BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
,C ADDRESS
L E ' BUILDING -ELECTRICAL-PLUMBING -MECHANICAL 940
0NEP' PLAN CHECK VALIDATION
NAME �yy� 'll) SN9'X12 QTY ELECTRIC PERMIT FEE
NT 4. 6Y5rgti%t6HDNE
CONTRACTOR
NAME UTLETS-SWITCHES-RECEP 10.00/1.00
N
LIC.NO. LIGHTING FIXTURES 10.00/1.00
DORESSNTRA oOs
AAPPLIANCES-RESIDENTIAL 4.00
CO
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT J PANELS (OVER 200 AMPI 20.00 PLAN CHECK FEE P.C.NO.
OP
ENGINEEP
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENc' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP. METER OR POLE INS. 20.00
APPLICANT MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
, 02 LICIiNSIiD CONTRACTORS DECLARATION TEMP.POLE 30.00 -7/31
a v U I hereby allirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
1- a '6" Professions Code,and my license is in full force and effect.
Z �z License Class Lic.Number ❑ ❑ ❑
o z -O Date Contractor
w t t
st m < , / BUILDING PERMIT
¢ ¢w ¢ OWNER-BUILDER DECLARATION INFORMATION
woAU MISC.- REFER TO ORD
;!LL N I hereby al firm that I am exempt frmn the Contractor's License VALUATION SIFT.
alto¢ Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00
t w� Code'.Any cityor county which requires a permit to construct,
W
Q ¢ ¢ p improve,denmlish,Or repair any structure,prior l0 its issuance,also ELEC.CONTR. LIC.NO. ELEC. �d
O u requires the applicant For such Re fn.it to file a signet)statement that TOTAL PERMIT TO
E
he is licensed pursuant to the provisions Of the CCiFtmclor's License AN J7
Hie
Law(Chapter`9(commencingwilh Section 7000)ofDivision 3 ofthe p
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE �"I Bee Pzq C.,M = $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
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 I$5001.1:
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00 OCG GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or ,(fared for sale (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00 I
Code:The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE \ j
himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however.the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the pro . . .
owner- GAS-EASYSTEM-OVER 4 (EA) 200 BUILDING USE
builder will have the burden of ving that he did not build or int- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 C1 El El El 13❑ I,as owner of the property,am exclusively contracting with
licensed contractors to construct the proper(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:'I'he Contractor's License Law docs 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)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. - PARCELNO.
❑ I am exempt under Sec. ,B.81'.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date
WATER SYSTEM 5.00 a ACG FILEN
ACC.DATE E 0.
WORK H COMPS, A'rION DECLARATION WATER TREATING EQUIP. 5.00
I hereby allirm that l have a ceNificute of c.nent to olf-insure,
or a certificate of Workers'Compensation Insurance,Or a certifieA ZONING ENG.SITE NO.
copy thereof(Sec.3800,LaNCA
Policy No. Company
❑ CertiNed ropy is hereby furnished. FIRE SPRINK ENERGY T 24
i Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y ❑ N❑ Y ❑ N❑
CC W CER'I'IFICA'1'17 OF EST MPTION FROM WORKERS' PERMIT ISSUANCE 1'r 10.00 FLOOD ZONE A.L.U.C.
LU > COMPENSAT'ION INSURANCE PLG.CONTR. LIC.NO. PLG.
0( This section, need not he completed if the permit is lar one TOTAL Y❑ N Y ❑ IN[J
hundred dollars($100)or less.) '.
CJ O (_certify that in the performance of tile work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I-. mit is issued.I shall not employ any person in any manner so as to
OU become subject to the Workers'Compensation Laws of California.
Ed BUILDING O
C. Datc APPhcam ALTER OR ADD TO MECH. 5.00 7 J
} m NOTICE: 70 APPLICAN'T': IL after making this Certificate of Ex-
F 2 ,option,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK 3
provisions of the Labor Code, you must forthwith.cmnply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
' CONST RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 ..
Ore performance of the work for which this permit Is issued(Sec. MICROFILM
3097,0,C), HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's
Name
Lcndch AAddrddoeHEATING UNIT(OV ER 100,000 B.T.U.0.50 ELECTRIC
h ss
I certify that l have read this application and sale that lhcabove 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 BOILER-COMPI3H.P.Or100,000B.T.U.) 6.00
hereby' authorim representatives of this city m enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments costs andexpenses which PERMIT ISSUANCE 10.00 CONST.TAX
ue
may in any way accragainst said City in consequence of [hc
granting this permit. MECH.CONT. LIC.NO. MECH.
V7 TOTAL TOTAL � 3-7
Si a arc I p II / o r to
INSPECTOR COPY