C9112 APPLICANT TO FILL IN INFORMATION WITHIN,RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING ' APPLICATION & PERMIT 9112
DDRES
BUILDING - ELECTRICAL-PLUMBING-MECHANI AL
OANER'I PLAN CHECK VALIDATION
\ ;`! "erne �� yrs{1/ /�C QTY. ELECTRIC PERMIT FEE PAID
�.A 1: . PRONE✓ / Q /
CTGFs
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
JUN
X SAM ii�' LIC NO LIGHTING FIXTURES 10.00/1.00
/ CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00
ADDRESS C�fi�1/I t
PHONE PANELS 10.00 OATBOFQEPGN
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE' P.C.NO. •V
OR
ENGINEER
uc.NO SIGNS TRANS. 3.00 L
AARCH.OR DDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
APPLICANT s
ADDDRESSDRESSMOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 /
0 0 0 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 (!/ J
u - I hereby affirm that 1 am licensed under provisions of Chapter 9 _ ISSUANCE DATE
N Z.
(commencing with Section 7000)Of Division 3 of the Business and BLD . ELECT. PLG. MECH.
F,v,z Professions Code,and ivy license a in full force and effect ❑ El Z o v, - License Class Lie Number
9 - Date Contractor
x f J BUILDING PERMIT
Ic rc w a OWNER-BUILDER DECLARATION INFORMATION
does " MISC - REFER TO ORD
u ti I hereby affirm that I am exempt form the Contractor .
License VALUATION
.. o a Law for the following reason.(Sec.7031,5,Brimessand Professions PERMIT ISSUANCE 10.00 S/FT.
� - Code:Any city orcouuty which requires a tit to construct,alteq i
m � Pero .
O improve,demolish,or repair any structure,poor to its issuance, ELEG CONTRLIC.NO.
also ELEC.
in
EEO Q requires the applicant for such permit to file a signed statement that TOTAL PERMIT T
n wm he is licensed W rsuant iD the provisions of the Contractor's License
Hzi
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
4 o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
at F o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a3by any applicant for a permit subjects rite applicant to a civil penalty gLTER
-DRAIN& VENT-WATER (EA.) 500
of not more than five handled dollar,(5500).)- p t
❑ I,as owner the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GRo RES.UNITS
' their sole compensation,
ion,will do the work,and the structure is nDi
intended or offered for sale (Sea 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code. The Contractor's License Law does not apply 10 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
^ himself or through his own employees,provided that such improve-
menisare not intendedoroffered for sale.If,however,the budding GAS-EA.SYSTEM-11NC.40UTLETS 6.00
ur improvement is sold within one year of completion,the owner-
GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE 1
-�/ builder will have the burden of proving that he did not build or ire- R IND CON PB Other
prove for purpose of sale.). I N DUSTR I A L W ASTE INTER. 30.00
❑ I,as owner Of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
andProfessions Code The Contractor's License Law docs n01'.aPPly -
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts I'or'Heh projects with a con[momm,)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt.Linder 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'COMPIiN'SATION DISCLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate Ofconmnt toself-insure, ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy lhereof(Sce.3800,Lal,CJ.
Policy No. Company
0 ❑ Certified copy is ruby fur ishW. FIRE SPHINK ENERGY T-24
Z.z ❑ Ceriifi- 'op Bled ' hnhcc me¢iiva erosion. MISC.- REFER TO ORD.
-O ApplicantY'❑ N❑ Y ❑ N❑
LU
My PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C.
CERTIFICATE F EXEMPTION PROM WORKERS'
W � COMPENSATION INSURANCE PLG.CONTR. LIC,NO PLG.
CL O (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
:D Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- FEE SUMMARY
LL F Hilt is issued,I shall not employ any person in any manner so as to QTY. MECHANICAL PERMIT FEE
0w become subject to the Workers Compensation Laws of California.
a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING �, s
} to NOTICE TO APPLICANT: If,after making;this Certificate of Ex-
� ? mnptiov.you should become subject to the Workers'COmpensatlat 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 10MOC.F.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE 7/)
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance i
of tie work for which ths permit is issued(Sea HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
Lender's Name
Lender's Addle HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
ss
I certify that l have read this application and state that the abuse VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city and county PLUMBING
�'' ce, and slete Taws relating to building construction, and BOILER-COMP(3 H.P.or 100,000B.T.U.) 6.00
+'7,4Myy authorize representatives of this city to 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 and expenses which CONST.TAX
ntay in any way accom against d City in Consequence of the PERMIT ISSUANCE 10.00
granting is perm MECH.CONT. LIG NO. MECH. /j61
/ I �Apw i�� TOTAL TOTAL r
S o Apphcantl � Dale t
INSPECTOR COPY -