9454 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION &PERMIT
ADDR /
V/ - I/L BUILDING-ELECTRICAL-PLUMBING'-MECHANICAL 9
454
0 ER'S PLAN CHECK VALIDATION
NAME /i/// QTY. ELECTRIC PERMIT FEE
. NTRA GJ�I Q PHONE
CONTRACTOR'S
/'1UTLETS-SWITCHES-RECEP 10.00/1.00
Ny.!�� ICA• LIGHTING FIXTURES 10.00/1.00
rorvrRAcroR's PPLIANCES-RESIDENTIAL 4.00
PANELS 10.00 DATE OF APPLICATION
ARCHITECTPANELS(OVER 200 AMP) 20.00 PLAN CHECK FEE D.C.NO.
ENGINEER
LIG.No. SIGNS TRANS. 3.00
ARCH.OR RE"G' SPECIALCIRCUIT S.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 t
APPUCANT's 54 MOTORS SEE FEE SCH. (ne'E>���•./
RE 5 Soe
SERVICE CHANGE 20.00 Qp
woo LICENSED CONTRACTORS DECLARATION I TEMP.POLE 30.00
Qv I hereby affirm that I am licensed under pmvi,ions of Chapters
aw ISSUANCE DATE
y (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F w z I'rofessios Cod',and m license is in full force and L E] ❑ ❑ ❑
Z o v, - License Class Lic.Number
9 y 0 Date Contractor
F
a a BUILDING PERMIT
rs w a IiR-BUILDCH DECLARATION
o a u INFORMATION
w g LL N I hereby al firm that I am exun,Pt Irnm the Contractor's License MISC.- REFER TO ORD
VALUATION $/FT.
F ,s D j Law Code:Any city
Ing reason.(Sec.7031.5.l must to Professions' PERMIT ISSUANCE 10.00 +
Code:Any city or county which req uirau permit to const,Let,ulmla
ac ¢ ¢ improve,demolish,or repair any scocture,Prior to its issuance,also ELEC.CONTE. - LIC.NO. ELEC.
D c requires RIC applicant for such permit 10 file a signed statement(lot TOTAL PERMIT TO
w he is licensed pursuant to(he pruvisionsof the Contractor's License
rzi
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE OlT
f m the basis for the alleged exemption.Any violation of Section 703 L5 STORIES TYPE CONSTR.
a : by any applicant for a Peru,.(subjects the applicant to a civil penalty
oI not more than five hundred dollars 18500).): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ I,as owner of the Property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 DCC.GROUP RES.UNITS
their sole compensation,will do the work,and Ore structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS LOOR) OOF,AR EA,CON D. 5.00
Code:The Contractor's License Law does not apply to an owner work
property who builds or Improves thereon,and Who does shell WOfk FIXTURES-PER TRAP 5AO 7 C6 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself orthmm,lb his own en.ployees,provid'J(hat such improve- GAS-EA.SVSTEM-11NC.4 OUTLETS 6.00
ments are not intended or offered I'or sale.If,however,the building
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or . BUILDING USE
Proveforpurposeofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sea 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractods)licensed pursuant to SEWER ITAR - TORM EA.200ft/10.00 CIV-
the Contracts!s License Law. / TRACT NO. PARCEL NO.
O I am exempt under Sec. ,B.&1.C.for this WATER HE /VENT 6.00
reason
Owner .Date WATER SYSTEM 5.00 ACC.DATE ACC FILE NO.
WORK FRS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certilicute ofcnnsenf to self-insure. ZONING ENG.SITE NO.
or a certificate of Worker"C pens:tion Insurance,or a Ger ified
Copy
tIt�.a�yC4 S J.
I'olic�alyl�� ny
❑ rnRc opy¢bercb 1'u niahcd. FIRE SPRINK ENERGY T 2
Z •Z A Cntlif iGd co y /le with ire city inspection division. MISC.- REFER TO ORD. v N v N
O ❑ ❑ ❑ ❑
CC T) CER'I'I'ICAE(F EXL,1 17R WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.c.
'LU > COMI'IiNSA'fCN INSURANCE PLG. T ,�E�,�11,, IC.NO. 'PLG.
CL O 1'1'It s section need not be completed if the permit is for one i /T 0 TOTAL.3V Y E] N El ❑ N❑
:3 Z hundred dolhus(S 100)or lessI
U O 1 cert:y that in the pcffunnance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued, I shall not employ any person in any.""I so as to
O w becon "se subject to the WorkerConnpensation Laws of California.
ED Date ApplicantBUILDING -
} W NOTICIi TO APPLICANT': IL after Inaking this Cutificate of fix- ALTER OR ADD TO MECH. 5.00
2 mnption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of tine labor Code, you most forthwith comply with FEE
U such provision or thispermit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the psufunnance of the work I'or which this permit is issued(Sec. - MICROFILM
3097,CIv.CJ, HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and count• PLUMBING J0q
0
ordinances and state laws totaling to building construction, and BOILER-COMPO H.P.or 100,000 B.T.U.) 6.00 ,
hereby authorve 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 of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any ay ac uC against said City in conseq ence of the
gt tip of 11s p mi. MECH.CONT. LIC.NO. MECH.
�` Qac. �g� TOTAL TOTAL
Sliaitftmeo Iicant/Contractor Dae
INSPECTOR COPY