C9184 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -_USE BALL POINT PEN qAY , ',I' K (t
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER'
ADDRESS � APPLICATION & PERMIT ��,��
ADDRESS
BUILDING - ELECTRICAL-PLUMBING-MEC NI AL
•Ips^- wLAN CHECK VALIDATION"AME QTY. ELECTRIC PERMIT FEE
wS�
vRONE
co EAcrD s k NAME Q4OUTLETS-SWITCHES-RECEP 10.00/1.00
Ic.NO. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR APPLIANCES-RESIDENTIAL 4.00 die
ADDRESS n
+\ /If S.59N ANTowro r�I. vHON�/s PANELS 10.00 01_ DATE OF APPLICATION
HCHI + PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRRess ENG' SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH. 311, J
AooREss
-
10 SERVICE CHANGE 20.00
o o LICENSED CONI DECLARATION TEMP.POLE 30.00
¢ v I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the B'usinuss and BLDG. ELECT. PLG. MECH.
rD i Nofeotmot Code,and my license is in full force and effect ^
Z
0=o/ Licer Class / Lie.ContrNumbe
F Uute y '
_Q y s -ia 4-PS _ BUILDING PERMIT
¢ ¢ w 4U OWNER-BUILDER DECLARATION INFORMATION
wLL f- 1 hereby`affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
r LLov, Law for the following reason. 7031.5,Businessand Professions PERMIT ISSUANCE 10.00 (J _ VALUATION $/FT.
Code:Any city or county which requiresa permit to construct.alter,
.IS Q 2 improve,denholish,or repair any structure,prior toils issuance,also ELEC.CONTR. LIC.NO. ELE
at 0
DLL requires the applicant for such permit to file a Signed statement that TOTp� (p 7�^ PE"IT TO
sA w m he is licensed pursuant to the provisions of the Cuntmetor's License
F z i
Law Chapter 9(commencing with Section 7000)of Division 3 of ,ri/'�w
-s 4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT ` FEE ��If ✓✓
¢ I- a the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
.• n3`0 by any applicant lorapermit subjects the applicant toacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00 G 0�
,four more than five honored dollars($500).): ..
D 1,as owner of the property,or my employees with wages as BACK F LOW PROT@CT.DEV ICE 4.00 OCC.GROUP RES.UNITS 1
I' their sole compensation,will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Coda The Contractor's License Low does not apply to an owner of H
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 4 O sO.F .ICOOR AREA TOTAL eREACE
` lliii if or through his own employees,provided that Such improve- L
meats are not intended or offered for sale.IC however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
/ or improvement is sold within one year of completion.the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RE IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 1,as owner of the property,am exclusively contracting with El C3 El 11r 1 licensed contractor, ¢s cotruct the projectISec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO,
fand 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 centractorls)licensed puroem o - -S
h the C'ontractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 + TRACT NO. 'PARCEL NO.
D I am exempt under Sec. ,BAP.C.for this r WATER HEATER W/VENT 6.00 &V
reason .4` Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate ofermsent to self-insure ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE N0.
copy thereof(Sec.3800,Lab.C.). C
Policy No. C(;;nPany A a An
❑ Cerificd copy a hereby f., ished FIRE SPRINK ENERGY T 24
Z Z 9e Cerfific opy is filed stith Re city 'nspectio division. MISC.- REFER TO ORD. ❑ ❑ ❑' ❑
p^ A ice t Y N V N
ICE m CER 'If ICATIi
OF Ii XIiM I'I'I.N FROM WOR KIi RS' PERMIT ISSUANCE 10.00 !� FLOOD ZONE A.L.U.C.
' LL > COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
CL O (This section need not be completed'if the permit is for one TOTAL 9 7 v❑ No Y ❑ NO
Z hundred dollars IS 100)or less.)
IIF U O I certify that in the performance of the work for which this per, CITY. MECHANICAL PERMIT I FEE FEE SUMMARY
LL I- mil is issued,I shall not employ any.persom in any mann,,xD:is to
Ow become subject to the Workers'Compensation Laws of California. BUILDING '
' a Date Applicant ALTER OR ADD TO MECH. 5.00
} to NOTICE TO APPLICANT: 1L after making this Certificate of Ex-
F-. ? caption,you should become subject to the Wnrkeri Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this p shall be deemed revoked. AIR'9-IANDLING UNIT(TO 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IOAOOC.EM.) 6.00 SEISMIC FEE 40
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
it 3 e pedornence of the work fur which this permit is iuued ISMICROFILM
ec. HEATING UNIT(TO 100,000 B.T.U.) 8.00v'9
Lender's Name HEATING UNIT 100,000 B.T.U.)9.50 /67 6 -
Lender's Address ELECTRIC
1 certify that 1 have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00 54 Q-G
• information is correct. I agree to comply with all city and countyPLUMBING (nJ
ordinances and state laws relating to building.em,firuction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby autltorize representaGres of this city to enter upon the BOILER-COMP (Over 100.000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes. 3 0
(We) agree to save, Indemnify and keep hornless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which I CONST.TAX
may in any way accrue against said City in consequence of the s, PERMIT ISSUANCE 10.00 D`O
granting ofthis permit MECH.CONT. LIC.NO. MECH. p
W o rP Co 'AC tr,foFV C�•,I+r+c. TOTAL e1U TOTAL
3hg e o pp man ate - r
INSPECTOR COPY