9210r.
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FI CATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS - 9210 GA� Q
/ f7 a / NOR W I Ch AV. BUILDING-ELECTRICAL-PLUMBING -MECHANICAL try
OWNER'S PLAN CHECK VALIDATION
NAME ,A( ,r, W ` !� / QTY. ELECTRIC PERMIT FEE ( /�''^'^(y`�' ('(
I fI�'1 /V WA,v PRONE.fJ�J�O / � J��;1/ 7/7i/O Jr
NAAMQCONTRACTORS UTLETS-SWITCHES-RECEP 10.00/1.00 S7Jz,
LIc.No. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S
's PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00 DATE OF APPLICATION
OR
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.c.No.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENG, PERMIT CIRCUIT 5.00 PERMIT VALIDATION
APPLICANT S ZIP EMP.METER OR POLE INS. 20.00
ADDRESS MOTORS A SEE FEE SCH. )
DREs
SERVICE CHANGE 20.00
0 o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
u w I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
H a 'w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F y z Porf sexions Code,and my license is in fall force and effect. ❑ ❑ ❑ ❑
z 0 v, - License Class Lie.Number
o m w Datc Contractor
< x 4 BUILDING PERMIT
ac I[ w¢ OWNHR-BUILDER DECLARATION
0 11 INFORMATION
K
; LL w I hereby affirm that I um exempt from the Contractor's License MISC.- REFER TO ORD t'
1•. VALUATION
ra0j Law for the following reason.(Sec. uires a,ermit to
Professions PERMIT ISSUANCE AJUD ` /FT. j
Code:Any city or coo of y which requirese permit ID construct,alter,
rt ¢ c improve,demolish,or repair any structure,prior to its isumna,also ELEC.DONTR. LIG N0. ELEC. //�O
ac 0 K requires the appfc:mt for such permit to file a signed statement that TOTAL PERMIT TO
w u he is licensed pursuant to the provisions of the Contractor's License
V.
Law(Chapter 9(commencing with Section 7000)ofDivision 3 oftheMoL
4 0 Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
w F $ the basis for the alleged exemption.Any violation o'Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civilpenally gLTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).1:
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.uw TS
their sole compensation,will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business still Professions
Code. ROOF,AREA,CON D. 5.00
Code.The Contractors License Law docs not apply to ret owner of
property who builds Or improves thereon,and Who does Such work FIXTURES-PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided Omt such improve- 0. .
ments are not intended or offered for sale.IL however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is slid within one year of completion,the owner- GAS-EA.SYSTEM OVER 4 (EA.) 2.00
builder will have the burden of proving that h - .
e did not build or im- BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
❑ I,as owner of the property,am exclusively'contracting with El El El El El
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 docs not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contraefs for such projects with it contractors)licensed pursuant to
Oto Contra'ctor's License Law. SEWER-SAN ITARV-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ Iam'exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
OwRL' Date WATER SYSTEM 5.00
n. ACC.DATE ACC FILE N0.
N'ORKF-RS'COMPI?,X'$;\TION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofcnnsent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thcr.F(Sec.3800,Lab.C.T
Policy No. Company
O .❑ Certified copy is hereby furnished. RE$PRINK ENERGY T-24
Z Z .
❑ Certified copy Is filed with the city inspection division
FO Applicant MISC.- REFER TO ORD. yo N❑ Y ❑ NE]
CC h CER1'1tlCA'1'17OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD zo NE 'A.L.U.C.
W > COMPIiNSATION INSURANCE. PLG.CONTR. LIC.NO. PLG,
d Om y� N� Y � �
O (This section need not be completed if permit is for one TOTAL N
:3-Z ),.,,died dollar,(1100)or less.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- unit is issued I shall not employ any person in any manner so as fo
0 U become subject to IIIc Workers''Compensation laws of California
Dale Applicant ALTER OR ADO TO MECH. 5.00 BUILDING
}
GO N(1'I'ICB TO APPLICANT': If,after making This Certificate of fx-
f- Z emption,you 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 shall be deemed revoked AIR HANDLING UNIT TO 10=C.F.M) 4.00
CONSTRUCT'ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE /
sv :
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 punnif is issued(Sec. MICROFILM
3097,r's Na). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Add, HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's AJdress ELECTRIC
1 certity that I have read this application andrmation is correct. 1 agree to comply with all city and Lvumtstate that the above VENTILATION FAN (SINGLE) 4.00
®
information PLUMBING
ordinances and state laws relating to building construction, and
aaBOILER-COMP(3H.P.or IO0,000B.T.U.I 6.00 f
hereby thcrLo representatives of this city to ewer upon the BOILER-COMP(Over 100,000 RTUI SEE FEE SCH. MECHANICAL
abuse-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City at MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
m - -
ay in any way Ilecrue against said City in consequence of the
granting of fit.permit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signature]gnat lieant(:onir f or Da e v
,;. INSPECTOR COPY -
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