09533 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTI FICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 09533
ADDRESS
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 0 9 5 3 3
vvNER'S 12 a - PLAN CHECK VALIDATION
® NAMEACTORs - V /ybl QTY. ELECTRIC PERMIT FEE
PHONE
NAME OUTLETS UTLETS-SWITCHES-RECEP 10.00/1.00
IV
t4c.rvo, LIGHTING FIXTURES 10.00/1.00
CONTRACTORS R's
ADAPPLIANCES-RESIDENTIAL 4.00
CO
PHONE - PANELS 10,00 DATE OF APPL
Rcm E T PLAN CHECK FEE PC.NO.
oR PANELS (OVER 200 AMP) 20.00
ENGINEER 4 LIC. pp
c.NO, SIGNS TRANS. 3.00 p3 1995
ARCH Ess ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION -
ZIP TEMP. METER OR POLE INS. 20.00 City Of CUD,ertlO
ASMOTORS SEE FEE SCH.
ADDREDDRESSS
SERVICE CHANGE 20.00
SE o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
Q u I hereby affirm that I am licensed under provisions of Chaplet 9 ISSUANCE DATE
H G Ic'ommencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG MECH.
H mz probe ns Code,and icen
lse is in full force and effect. O
m
z o - License Class Lic.Number -) S(,0 ;` ❑
O w F w Uule -. Contractor
a m BUILDING P RMIT
Er S,
to OWNER-R-BUILDER DECLARATION INFORM ION
wy 1 hereb ffinG that I am excm l from the Contractor's License MISC.- REFER TO ORD
�+ 11 Ya p VALUATION SIFT.
H LL O 4 Law for the following reason.(See.7031.5,Businessand Professions PERMIT ISSUANCE 10.00
Code:Anycity orcounty which requiresa permit to construct.alter,
a, improve,demolish.or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO.
ELEC.
cI
LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w m m he is licensed pursuant to the provisions of the Contractor's License
H z s- Law(Chapter 9(commencing with Section 7000)of Division 3 oftle
E o Itusincss and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
Er H O the basis for tlm alleged c em pt ion.Any violation of Sect ion 7031.5 STORIES TYPE DNSTR.
'a _ � by any applicant for a pernin subjects life applicant to o civil penalty
of not more than five hundred dollar,($500L) ALTER-DRAIN& VENT-WATER (EA.) 5.00
❑ I,as owner of the property,or my enmloyees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC,GROUP RES.UNITS
their Sole compensation,will do the work,end Ilio sl rueture is not
intended or offered for sale (Sec. 7044, Business and ProfessionsDRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO,FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
�V mems are not intended proffered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00 00
or improvement is sold within one year of completion,lire owner- GAS EASYSTEM OVER 4(EA ) 200
builder will have the burden of proving that h - . - . .
e did not build or int- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER30.00 R IND CON PB Omer
.
❑ I,as owner of the property,ant exclusively contracting with ❑ ❑ ❑ ❑
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 does not apply
m:at owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contructons)licensed pursuant to SEWER-SANITARY-STORM EA.2001t110.00
the Contnmtois License Law. OV . RACY NO. PARCEL NO.
❑ l um exempt under Sec. ,B.&P.C.lin this WATER HEATER W/VENT 6.00 OU
reason
Owner Dale WATER SYSTEM 5.00 e-aO ACC.OATE ACC,FILE NO.
W'ORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby alGrm that 1 have a certificate ofconwnt toself-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.CJ.
policy No.-Company-
0
o. CompanyO O Certified Copyisherebyfunuislmd. FIRESPRINK ENERGY T-24
Z Z �(Certified py is 01ed with the city inspection division.
O ApPlieLnt- r 3 MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
OC W CERTIFICATE OF EXI:MP1ION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU �_ COMPENSATION INSURANCE PLG.CONTH. LIC.NO. PLG. t•yy
CL O (This sectic. need of be completed if the permit is for one TOTAL {/`- Y[:] N -] Y❑ N❑
D Z hundred dollars IS 100)or IcssJ
U O 1 cerlify that in the performance of file work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
1..L U nut is issued, I shall not employ any person in any mamter so as to
become subject to the Workers'Compensation Laws of California.
O OL.LU Dam Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
H Z empfion,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 10MCF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IQOWC.F.M.) 6.00 SEISMIC FEE
I hereby af0rn 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.L HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
L
I certify that l have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
indinaec on n correct I agree to comply with all oily and county PLUMBING nU
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby autlmdLte representatives of this city to enter upon the BOILER-COMP (Over 100.000 BTU)SEE FEE SCH. MECHANICAL
above-menliuned'properly for inspection purposes.
(We) agree to save, indemnify and keep harmless the�City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
grants oft permit. /� / MECH.CONT. LIG NO. MECH.
. AQ pa F41 [�� TOTAL TOTAL
Si !c nth o c ��I�iC�
INSPECTOR COPY