9348 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT lDENTI FICATION PERMIT NUMBER
APPLICATION & PERMIT,
rout-DING
EGRESS
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 9348
OWNER'S PLAN CHECK VALIDATION
NAME CITY. ELECTRIC PERMIT FEE
. ovPE/L PRGNE
CONTnACTOR5OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME
A't` uc.No. 983Sg LIGHTING FIXTURES 10.00/1.00
CADDRESS roll's G07TJlI , rqt, �o�) PPLIANCES-RESIDENTIAL 4.00
.WIWO/NAI yL PHONE 3re.2 g? % PANELS 10.00 DATE OF APPLICATION
RmRrECT PANELS (OVER 200'AMP) 20.00 PLAN CHECK VEE P.C.NO.
O
OR
ENGINEER
UC.No. SIGNS TRANS. 3.00
ARC..OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00 );
APPLICANT'S PAID
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 JUL 2
wz.
o O LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 195
u. I hereby affirm that 1 um licensed under provision,of Chapter 9 UANCE DATE
a n (commencing with Section 7000)of Division 3 of the Business and BLDG. E ty. el�Je ) CH!
H N z Professions Code,and my license is in full force and effect.
z
0. - License Class Lic.Number -3-Ji.423��
9 z9 w .Date 1
lw! _ �Contmdor
r H �7-� .-
m a ¢ OWNER-BUILDER DECLARATION BUILDING PERMIT
- 0 a, - INFORMATION
oA , MISC.- REFER TO ORD
F
LL y I hereby affirm that I am exempt from the Contractor's License VALUATION S/FT.
u o< Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 10.00
rN0 Code:Anycity orcounty whichrequiresapennit to construct,alter,
ac ¢ Q 2O improve,demolish,or repair any structure,prior W its issuance,also ELEC.CONTR. LIG N0. ELEC.
G ¢ requires the applicant for such permit to file a Signed statement that TOTAL PERMIT TO
w m he is licensed pursuant to the provisions of the Contractors License
R z r Law(Chapter 9(conmtcncing with Section 7000)of Division 3 of Dtc
- a Business and Professions Code)or that he is exempt therefrom and GTY. PLUMBING PERMIT FEE
the basis for the alleged exemption.Any violation of Sect ion 7031.5 1 STORIES TYPE CONSTR.
I-_ any applicant to,a permit subjects the applicant to.civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than Ove hundred dollars(55001.):
❑ I,as owner Of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will it,,the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-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 TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
meets are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, the owner. GAS-EASYSTEM-OVER 4 IEA) 200 BUILDINGUSE
builder will hove the burden of proving that lie did not build or in, . . .
R S IND CON vB Omer
prove 1,as owner
of sale.). INDUSTRIAL WASTE INTER. 30.00 0 ❑ ❑ ❑
❑ d as owner of the property,he exclusively contracting with
licensed contractors to construct the priced(Sec 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The who
License Law docs not apply
to contracts
owner of property who builds tr improves thereon,and whot to LAWN SPRINKLERS-OVER 5(EA.) 1.00
the Cont four's L projects with a contractors) iccnscd pursuant to
the Contractor's License Law. I SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACG FILE NO.
WORK ERS'COMPENSATION DECLARA'noN WATER TREATING EQUIP. 5.00
I hereby AfonI that I have a certificate of consent to clf-insure. ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. - Company
Q ❑ Certified copy is hereby furnished FIRE SPRINK ENERGY T 24
.Z 2 ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O Appliami YE] NE] Y E] NE]
PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
Lu CIiRTI FICCONIOI°SArpoN INS FROM WORKERS'
W 7 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
O'Z hundred dollars(5100)or Iess.) -
U O I certify that in the performance of the work fir which this per CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mil is issued,1 shall not untpl.y any person in any manner so as to
Qcarw become su )ect ..U+Workers'Compensa tion Lawsof California. BUILDING
u Datc (J?+.�JX� Applicant� ALTER OR ADD TO MECH. 5.00
} y N'O'1'1 :ref 1N API'LICAN'1': If,aHer mak crH t-C" e�F1',c
F ? emption,you should become subject to the Workers'Compensation IF APPLIANCE5.00 LAN CHECK
provisions of the Labor Led, YOU must forthwith comply with FEE
U such provisions or this permit shall be donned revoked. AIR HANDLING UNIT ITO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p00GF.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
30e performance 97, ICROFILM
of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.UJ 8.00
Lender's Name
NHEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Name ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 41
• information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-ODMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100000 BTU)SEE FEE SCH. MECHANICAL
e
abovmentioned property for inspection purposes. e�
(We) agree to save, indemnify and keep harmless life City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses whichPERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
graNing of this permit. - MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signature.-A pt ant Cmtractor etc
rs INSPECTOR COPY
N