9159 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LD ING PROJECT I DENTIFICATI ON PERMIT NUMBER
BUILDING !!,�� APPLICATION & PERMIT 9159
ADDRESS r -fLDING-ELECTRICAL-PLUMBING -MECHANICAL
C7 � �
OWNER'S PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
• K ONE
Lo cio OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME
/ Nf'0. uc.No. C7 LIGHTING FIXTURES 10.00/1.00
l CONTRACTOR'S yAPPLIANCES-RESIDENTIAL ' 4.00
ADDRESS a
e�lCi PIroNE YS PANELS 10.00 DATE OF APPLICATION
RLR(T T PANELS (OVER 200 AMP) 20.00PLAN.CHECK FEE P.C.NO.
OR
O
ENGINEER
uc.No. SIGNS TRANS. 3.00 Al
ARCH.OR ENG. PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00 --
ZIP TEMP. METER OR POLE INS. 20.00
APPLICANT'S MOTORS SEE FEE SCH.
Aoo E e'
SERVICE CHANGE 20.00
0 0 of LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
G u u J/ I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
m <H (commencing with Section 70001 of Division 3 O(ihc Business and BLDG. ELECT. PLG. MECH.
z F y z Professions Code,and my license is in full force and effect. ❑ ( ❑ ❑
o m - License Class Lic.Number
O w Date Contractor
¢ xUIL
OWNER-BUILDER DECLARATION ING PERMITINFORMATION
wg LL I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION 5/FT.
F LL 0 4 Law for the following reason.(Sec 7031.5,Bmanessand Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
¢ ¢ <a improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC.
re
- 0 LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
A Le m w he is licensed pursuant to the provisions of the Contractor's License
FZQ
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
4 0 Business and Professions Code)or that be is exempt therefrom and OTY. PLUMBING PERMIT 1 FEE
¢ r o the basis for the alleged exemption.Any violation"(Section 7031.5 ST ES TYPE CONSTR.
dF_ m by anyapplicanl(or a permit subjects tiro applicanttoo civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars(5500).1:
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is out
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:Tire Contractor's License Law dues not apply to an owner of
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself a through his own employees.provided that such improv"
menton throuhh isot or offered for nempoyees, moved that suhebuilding GAS-EA,SYSTEM-11NC.40UTLETS 6.00
or improvement Is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.( 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 R IND CON PB Omer
❑ I,as owner of the property,run exclusively contracting with ❑ , ❑ ❑ ❑
licensed contractors to construct Orn project(Sec. 7044, Busine% LAWN SPRINKLERS:1 INC 5 V.B. 8.00 ASSESSORS PARCEL N0.
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 u contmctorts)licensed posemn to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ la in exempt under Sec ,R.&P.C.Rn this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARA'FON WATER TREATING EQUIP, 5.00
1 hereby affirm that I have Ir certificate of conicnl to self-insure. ZONING ENG.SITE NO.
o a certificate ,f Workers'Compcnsat ion Insurance,o rtI ied
copy the f ".3 ulp'ny.1-� r� (f/nGG'�
.,/� Policy. slic"byvT lY
QX` t1 c is hereby furnlxhcd. FIRE SPRINK ENERGY P24
Z 2O y{"'art tied eo�y is filed witl c clfy :p Gan-Ai cion. MISC.- REFER TO ORD. Y ❑ N❑ y ❑ N❑
/f[i leant
~ N �.�/ PERMIT ISSUANCE 10.00
M > iR CA'r L'OF EXEMI ON FROM\ FLOOD ZONE A.L.U.C.
W COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL o (This section need not be completed if the peund is fur one TOTAL Y❑ N❑ Y ❑ N❑
Z hundred dollars IS 100)or Iess.l
U O 1 certify that in the performance of the work 1'or which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in any manner n,as to
V become subject to the Werkers'Compensution Lawsof California. BUILDING
a
DateAppOcant ALTER OR ADD TO MECH. 5.00
} W NOTICE TO APPLICANT: If,after making this Certificate of Us-
eruption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you Most 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.EM.) 6.00 SEISMIC FEE
I hereby affirm 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.CJ, HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and state that the ulm c VENTILATION FAN (SINGLE) 4.00
• information is correct. I egree•to cmnply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BO -713(H.P.or 100,000B.T.U.) 6.00
.hereby authbrizu representatives of this city to enter upon the BOILERILER -COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection Purposes.
(We) agree to save,Ardemnify and keep harmless Ole City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said C' in consequence of the PERMIT ISSUANCE 10.00
gmnitiI is permit. ) MECH.CONT. LIC.NO. MECH.
TAL
y� _ TOTAL
�V at licant " ctor mL
INSPECTOR COPY