9275 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BU,LmNc APPLICATION & PERMIT
_I ADDRESS
T BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 9275
1 PLAN CHECK VALIDATION
NAME GTY. ELECTRIC PERMIT FEE
-• �TIRS PSI:
PHONE
CONTRACTO1 UTLETS-SWITCHES-RECEP 10.00/1.00
Vi
LIC.NO. LIGHTING FIXTURES 10.00/1.00
DD
ADDDRESSRESS 's APPLIANCES-RESIDENTIAL 4.00
ADDRESS
T1 H STFJ \rtPHONE PANELS 10,00 DATE OF APPLICATION
AROR
LNECi U� L PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER -�
LIC.NO. SIGNS TRANS. 3.00
ARCH,OR ADDRESS ENG _-'' nk SPECIAL CIRCUIT G 5,60 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS- 20.00 A -
APPLICANT
ADDRESS MOTORS SEE FEE SCH. PN,D
SERVICE CHANGE 20.00
Hoa LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
JUL 1219F�
¢ u w hereby affirm tot I am licensed under provisions of Chapter 9 ISSUANCE DATE
y a H (Commencing with Section 7000)of Division 3 of the Business and 1St--ley
MECH.
F y z Professions Code,and my license is in full force and e�ff
0 License ClassN
_2i Lin. u
9 f L'7Z
m H LeDaf@l,.t #•a�2�1 Contract.,torT_�``�Z�TTJJ
BUIL NG PE MIT
¢s w< OWNER-BUILDER DECLARATION IN ORMAT M
R
;a. y I hereby affirm that I am exempt Iron the Contractor's License MISC.- REFER TO ORD
a_ o¢ Law for the following reason.(Sec.7031.5,Businessland Professions PERMIT ISSUANCE 10.00 VALOATION
- mom Code:Any city or county which requires.a permit loconstruaLalRr,
¢ m> pr F y prior to its issuance,also ELEC.CONTR. LIC.NO.
¢ a improve,demolish,or repair an structure,{ri ELEC.
o. wo ¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
u he is licensed pursuant to the provisions of the Contractor's License
rzi
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
¢ Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r o the basis for the alleged exemption.Any violation of Section 7031.5 RIES CYSTR..
n ; by any applicant fora permit subjects the applicant loacivil penalty
of not more than five hundred dollars(5500).): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ Gore owner of the property,ur my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC. R NITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:']lie Conlractur's License Law does not apply to un owner ld
prOp,rty who builds or llll prove,therenl1,and WI1lt doC$fiuCl Work FIXTURES-PER TRAP 5.06 S°.FT.FLOOR AREA TOTAL ACREAGE
. menus are of ugh mend is ownemfor
if,
however,the
ihaddiaprevGAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00
mems are not t is sold or thinooffered for Sulu.If,however,the building
or im r will have
is sold Within one you of cont id...n,tire owner. GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or all.
prove for Purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RE IND CON PB Other
❑ I,as owner of the property,um exclusively contracting with ❑, ❑ El El
licensed conlractora 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
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 contruclons)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ l urn exempt under Sec. ,B.&P,C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to sell-insure. ZONING
or a certificate of Workers'Compensation Insurance,or a cerlificd f-4 A C ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy N'o. Company,r n� A l a Ss 0 r s l
C) ❑fl Certified copy is hereby f rn shed. 1 "mow
Z Z TCcrlificd copy I, filed with the eily inepeclion division. FIRE,PRINK ENERGYT 24
MISC.- REFER TO ORD.
O ➢plica t Y N� Y N�
~ N PERMIT ISSUANCE 10.00
� C RTIIIG\Tfi OP li%f:MPTION PROM WORKIiRS' FLOOD ZONE A.L.U.C.
W . COMPENSAT ION INSURANCE PLG.CONTR. LIC.ACTPLG.
CL Z (This section need not be completed if the permit is for one TOTAL V N� Y El NID
hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- GTY. MECHANICAL PERMIT FEE FEE SUMMARY
Uk_ 1- mil is issued,I shall not ernph y any person in any manner so as to
o U become subject to the Worker Compensation Laws of Califorria.
Q_ Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex.
F 2 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
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for 1 EXHAUST HOOD (WITH DUCT) 5.00
the performance ofdhe work for which this permit is issued(See MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name - HEATI NG UN IT 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
1 certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree In comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above mentioned proparty for inspection purposes. BOILER-COMP IOver 100.000 BTuI SEE FEE SCH. MECHANICAL 19
(We) agree to save, indannity and keep harmless the City of MISC.- REFER TO ORD. 371
Cupertino against.liabilities,judgnnenLs, costs and expenses whichPERMIT ISSUANCE - 10.001CONST.TAX
may in any way accrue against said City in con convince of the
grunting of this pcnnl(t„ MECH.CONT, LIC.NO. MECH.
es)r l I . n\ \so . uuAt ��,, TOTAL TOTAL
Slgn�url f h Co Ver r 4`^+'V �" Dare"� - l
N� INSPECTOR COPY
I