9282 APPLICANM.-TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU ILDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS 9282 n 2
BUILDING -ELECTRICAL-PLUMBING-MECHANICALV9G L
DINNER'$ - PLAN CHECK VALIDATION
• QTY. ELECTRIC PERMIT FEE
A.
4
CCATRACTO.'5
rvAME OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC (st( / LIGHTING FIXTURES / 10.00/1.00
-o TRALTDFs
AOD ss PPLIANCES-RESIDENTIAL 4.00
PRO. l PANELS 10,00 DATE OF APPLICATION
OORRLM EC PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. ` 3.00
ARCH.OR ENG. PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00
ZIP TEMP. METER OR POLE INS. 20.00 n
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
.<
r wISE
' SERVICE CHANGE 20.00
o o LICENSED CON7BACTORS DICLARAf10NI TEMP.POLE1O" -
30.00
1s Fi w 1 hereby affirm that I am licensed under provisions of Chapter 9 +• ISSUANCE GATE
a n (commencing with Section 70 00)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r H i Professions Code,and my license is in full force and if
❑ ❑ ❑
Z: o m- License Class _ Lic.Number
9 w F 0 Dalc Contractor -
a Y E BUILDING PERMIT
¢ ¢ ¢ OWNER-BUILDER DECLARATION
a a O INFORMATION
¢ r I hereby,affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
r• u O 4 Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION S/FT,
Code:Any city or county which requires;I permit to construct,alter,
' in ¢ ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CO TR. LIC-NO- ELEC. �..+
ca
O ¢ requires the applicant lin such permit to file a signed suer cat that TOTAL
w m he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
Hz >
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthc
s 4 o Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEELEG7
¢ I- the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) $.00
of not more than five hundred dollars(SS00).):
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEV ICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for at, (Sr, 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 '
Code:The Contractor's License Law does nut apply to an owner of
property who builds hp ove thereon,and who)does such work FIXTURES-PER TRAP 5.00 $D.FT FLOOR AREA TOTALACREAGE
himself or through hisown mployees provided that such improve- GAS-EA.SVSTEM-1 600
ry lents are not int gthred for sale.If,however,the building _ _
,or improveme old ithf,onesyciw l'complet or 'the owner- r •r - __.- _ - '1
�k"i ' udder wdl ha Wdet`R of proving that he did not build or inn- GAS'-,EA:'SYSTEM--OVER 4'(EA.)"- -200'. - BUILDINGVSE - '-
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
E] El El D 1:1❑ I,as owner of the progeny,am exclusively contracting with
licensed contractors to construct the project(See. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 y ASSESSORS PARCEL NO.
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 a contractons)licensed pursuant to SEWERSANITAR V-STORM EA.2001t/10:00
the Contractors License Law. TRACT NO. PARCEL NO.
O •l um exempt under Sec.-,B.&P.C.to,this WATER HEATER W/VENT _6.00 '
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
W'ORKF-RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of-consent to sel Ginsurs.
or a certificate of Workers Compensation Insumnce,or a certified -NZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.)- N,
Policy Nn. Company '
O C Ccrtdaad co y is li by famish d.
Z Z -� Cerl Jle p ytiW-111E'a ction division. FIRESPRINK ENERGY T-24
PO Appllcant �.� i MISC.- REFER TO ORD. Y � N� Y [] NE]
CC L4 CERTIFICATE 017 EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LLQ CC,NiPEN'SATION INSURANCE PLG.CONTE. LIC.NO. PLO. � N� Y � N�
CL 0 ('Phis section need not be completed it the permit is for one TOTAL
Y
U O himdreddollars(S100)ode's.)
I certify that in the performance of lire work for which this Per- GTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall not enmloy any person in any manner so as to y
O w r become subject to the Workers'Compensation Laws of California.t
Dale Appli°ant '' ALTER OR ADD TO MECH. 5.00 BUILDING
>_ w NO ITCH TO API'LICAN'I': If,after making this Cert ificale of Ex-
Z_ emplion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions orlhis permit shall be deemed revoked. AIR HANDLING UNIT(TO 10AOOC.F.NL) 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10DWC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of tire work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender,Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 /1
Lender's'Namress - ELECTRIC
I C
I certify that l have read this application and state that the above VENTI LATION FAN (SING LE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
0 ordinances and state laws relating to building constmclion. and BOILER-COMP(3 H.P.or100,000B.T.U.) 6.00
hereby authorize rep,m-nlalives of this city to enter upon die BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above mentioned property for inspection pure
(We) agree to save, indemnify and k• uumlcss the Ciry of MISC.- REFER TO ORD.
Cupertino against liabilities,judgment sis anA expenses which PERMIT ISSUANCE 10,00 CONST.TAX
may in any way rue against ity in consequence of the
grunting or nit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
I pffcarn/CiTntraichie [c
INSPECTOR COPY -