C9304 APPLICANT TO FILL IN INFORIXATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTIF16ATY&
PERMIT NUMBER
/ BUILDING APPLICATION & PER 93G4
X ADDRESS
BUILDING—ELECTRICAL—PLUMBING—MECHANICAL
n
OwrvE 'B - PL CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
/"VHONE
NAMER cr OUTLETS-SWITCHES-flECEP 10.00/1.00
(, r, A LIC.No. LIGHTING FIXTURES 10.00/1.00
co RACTOR's
ADDRESS PPLIANCES-RESIDENTIAL 4.00 '
S•'J,
PHONE 7 7qa Q en PANELS 10,00 DATE OF APPLICATION
ARC TCT PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
LIC.No. SIGNS TRANS. 3.00
_ AACWOR ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP EMP. METER OR POLE INS. 20.00
APPLICANT'$
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00 IN
o¢ TEMP.POLE 30.00 -7 14-10C-
,02 S
a LICENSED CON'PRACTORS DECLARATION
¢ea I hereby affirm that I am licensed under provisions of Chapter 9 1 ISSUANCE DATE
Ha N (commencing with Section 7000)of Division 3 of the Business and BLD ELECT. PLG. MECH.
H y-Z Professions Code,and my license is in full force and effect. ❑
z 0 w License Clain G 1 Lie Number
0 H Late ��T_Contractor
P y E < ` �� I. BUILDING PERMIT
¢ ¢ ¢ OWNER-BUILDER DECLAR, I'1 N INFORMATION
wo a H 1 hereby affirm that I am exempt from the Contractor's License MISC.— REFER TO ORD )
3 u w VALUATION $/FT.
FLLD¢ Law for the following reason.(Sec.7031.5.Business l'rofesxions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct.alter,
¢ ¢ Q p improve,demolish,or repair any structure,prior to its issuance.also ELEC.CONTR. LIC.NO. ELEC. / '
u
- O ¢ requires the applicant for such permit t0 file a signed statement that TOTAL PERMIT TO
w m he is licensed pursuant to the provisions of lire Contractor's License
al z 4¢ Law(Chapter 9(Commencing with Section 7000)of Division 3 ofthe i x
E D Business and Professions Code)or that he is exempt IhcrcOan and QTY. PLUMBING PERMIT FEE 71e2 f9l
¢ I-m the basis for the alleged exemption.Any violation of Section 7031.$ STORIES TYPE CONSTR.
byany applicant lora permit subjects the upplicanuoacivil penalty ALTER-DRAIN -WATER IEA.) 5.00 of not not more than five hundred dollars(5500)):
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE '-4.00 OCC.GROUP BEs.UNITS
sole conspenution,will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Boancss and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
'Code:'Fire Comractor's License Law don'not apply to an owner of
property who builds or improves thercon,and who does surch work FIXTURES-PER TRAP S.00 EO.FT,FLOOR AREA TOTALACREAGE
himself or through his own Cnlployecs,provided that such improve-
.� melts are not intended or offered for sale.If,however,the building GAS-EA.SVSTEM-11NC.4 OUTLETS 6.00
or improvement is sold within one year of completion, o
the wner- GAS-EASYSTEM-OVER 4 IEA) 200 BUILDING USE
builder will have the bu N . . .
an UI proving Ilial he did not build or int-{ IND CON P
m O Orion
a'prove for purpose ule.). INDUSTRIAL WASTE INTER. 30.00 .. 1:1 El ❑ 1:1❑ I,as owner of the property,aexclusively eontracling will) t
licensed contractors to construct the profeel(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:'I'he Contractor's License Law docs 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 contractorls)licensed pursuant to
tire Contractor's License Law.
SEWER-SAN V-STORM EA.2001t/10.00 n TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,R.&I'.C.for this WATER HEATE W/VENT 6.00
reason
Owner Dam WATER SYSTEM' \ 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPFNSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a Certificate ofconout Up self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a cert_iticd
copy thereof(Sec.3800,Lab.C). -
Policy N'o. Company
O ❑ Certified copy is hereby(unYisilcd. FIRE SPRINK ENERGY T-24 `
Z 2 ❑licant Certifie copy is filed with tlsc city inspection division.
MISC.- REFER TO ORD.
pY❑ No , Y ❑ IN F]
WORKERS
cc: w CIiRTII:tfyN E XIiA1I'TION FROaI ' PERMIT ISSUANCE 10.00 FLOOD ZONE at..u.c.
L Of, OF IiPENSA'I[ON'INSURANCE PLG.CONTR. LIC.No. PLG.
EL Q (This section nee) not be completed if the permit is for one TOTAL — Y❑ IN E] Y [:] NE]
Z hundred dollars($100)or Is..)
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
U: F mit is issued,I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California. BUILDING SQ
d Date Applicant ALTER OR ADD TO MECH. 5.00
} W NOTICE' TO APPLICANT: If,after making this CCUificate of I
♦— 2 eiPtion,YOU should become subject to the Workers'Compensation APPLIANCE '5.00 PLAN CHECK
provisions of the Labor Code, YOU must fortllwith comply with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10AOOC.F.M.) 4.00 FEE
CONSTRUCTION LIiND1NG AGENCY AIR HANDLING UNIT(OVER 10A0DGEM.) 6.00 ' SEISMIC FEE
1 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.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC �•�
I Certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
/✓• information is correct. I agree to Conl Ply with all City and county BOILER H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and slate laws relating 10 holding construction. and
hereby authorize representatives of this city to enter upon the 801 LER-COMP IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly for inspection purposes.
(Wc)agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consul tun ce of lire
granting of this permit, MECH.CONT. LIG NO. MECH. p
TOTAL TOTAL
Signa urcoAAp IicanlfContractd[ Jatc
L. ✓✓�� INSPECTOR COPY