9190 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
APPLICATION & PERMIT
BUILDING -
AooREss 9190
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL'
OWNER'S r /_• PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
/ GONE
ll
NAME ACTORS UTLETS-SWITCHES-RECEP 10.00/1.00
Duc.No. LIGHTING FIXTURES 10.00/1.00
D A
AooT A vs PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 10.00s DATE OF APPLICATION
A H re
Dfl PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER LIC,NO SIGNS TRANS. 3.00
AARCH.OR DDRESS ENG. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
APPLICANT'S EE F
MOTORS SEE SCH.
ADDRESS r ) 1
SERVICE CHANGE 20.00 ?j
w o O LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
ac at Q
U y I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
h1 (commencing with Section 7000)of Division 3 0l the Business and
Q n BLDG. ELECT. PL MEC
Hai Professions Code,' my license is in full force and effect. ❑ ❑
pz.N+O License Class_ Lia Number
F rn H j� Date ontmctor
¢ Y E BUILDING PERMIT
a w u OW FiR-BUILDER DECLARATION INFORMATION
E
3 LL R I hereby aflinn Ihat I am exempt from the Contractor's License MISC.- REFER TO ORD vhwAT10N $/FT.
H u O J Law Iia the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00
Coda:Any city or county which requires a permit to construct,alter,
K ¢¢ 2 tmprrv,demolish,nr repair any structure,prior to its is.vuunec,also ELEC.CONTR. LIC.NO. ELEC.
-DLL requires the applicant for such permit to file a signed statement that TOTAL PERM T TO
wm he is licensed pursuant to the powtsions of the Contructur',a License
rzi Law(Chapter 9(comnencing with Section 7000)of Division 3 of the
Q Business and Professions Code)or that he is exempt therefrom'und DTV. PLUMBING PERMIT FEE
¢ = 0 lire basis for the alleged exemption.An
gc ti
phe violation t Section malty STORIES TYPE CONSTR.
s g of any applicant fore hundred
subjects 5000.licam tea civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00 t
of not mase wee five hundred dollars(my em):
❑ Las owner at the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 �'( � OCC.GROUP RES.UNITS
iratesole compensation,will(S the work,and the structure is not .
intended or offered for sale(Sec. 70Business and owner ox DRAINS-FLOOR,ROOF,AR EA,CON D. 5.00
Code:The Contractor's License Law does not apply t0 atn uwma of
property who builds or improves thereon,and who docs rump work FIXTURES-PER TRAP 500 Y,��� SD.FT.FLOOR AREA TOTAL ACREAGE
® himself or through his own employees,provided that such int building
f
me improvement
or within
onefor
year
lhowever,thetthe ower- GAS-EA.SYSTEM-11NC.4OUTLETS 6.00
or lder will hav 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 M1uiIJ or itm
Prove for purpose ofmle')' INDUSTRIAL WASTE INTER. 30.00 - RES IND CON PB Other
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors IV construct the project(Sec 7044,Business LAWN SPRINKLERS-I INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code.The Contractor's Li cense Law docs not apply
to an owner of property who builds or improves therein,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
conoucts forsoch projects with a contractor(s)liccnscd pursuant((Ithe CooGaCHI,I License Law. SEWER-SANITARY-STORMEA.200ft/10.00 (( / TRACT No. PARCEL NO.
❑ tum exempt under Sec. ,li.&I'.C.tis this WATER HEATER W/VENT 6.00
rd'wH
Owner Dale WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'CONPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have.certificate dconsent to w9Gimm'.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENO.SITE NO.
copy thereof I Sec.3800•Lab C.).
Policy No. Company
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z_ Z ❑. Certified copy is led with the city is clion division. MISC.- REFER TO ORD.
O ilpplicunt Y ❑ N❑ V ❑ N❑
HN I PERMIT ISSUANCE 10.00 PLOODZONE A.L.uc.
Ir CERTl19G1'I'F:OF'fiX-' ION FROMWORKfSRS'
LU � COMPENSA ION INSURANCE PLG.CONTR. LIC.NO. PLG.
3-0 This welmn need not be completed if the permit is for one TOTAL IAY❑ N[] Y[:] N❑
bonded dollars IS 100)or Ica.)
U O 1 certify that in tire performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I-, mit is issued,I shall not employ any peri,,.in any nlanndrso us to
O W bec011le suhjecl to the Worked n
Contetion Laws of California. BUILDING
a Dale-Applicant ALTER OR ADD TO MECH. 5.00
} tD NO'I'ICF 'ID APPLICANT: If,after mukims this Certificule o1'Ex-
? eruption,you should become subject to tine Workers'Compensation APPLIANCE 5.00 PLAN CHECK
P'r' of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10SMC F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 �
the 3097.performance
CivC arm MICROFILM
of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 P /
Lenders Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address 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 comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.of 100,000 B.T.U.) 6.00
hereby aulhurize 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 o1MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 1000 CONST.TAX
.
may in any way accrue against said City in consequmnce of the / 1.
grantingins this pen..it, MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL /
Sign a on ac U i
INSPECTOR COPY