C9321 APPLICANT/40 FILL IN'INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
g�• BUILDING'PROJECTIDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS C
'C BUILDING-ELECTRICAL-PLUMBING -MECHANICAL 9321
PLAN CHECK VALIDATION
NAME T.i IRGNtI. QTY. ELECTRIC PERMIT FEE t
CCNTEAcTDRIS�'
y� NAMEOUTLETS-SWITCHES-RECEP 10.00/1.00
ErLJW LIC.No. LIGHTING FIXTURES 10.00/1.00
i .ONTRACTDRB APPLIANCES-RESIDENTIAL 4.00
ADDRESS Fo=rc-irl
zwtA le 9111.1 �e II PHONE!114 PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER LIC.No. SIGNS TRANS. 3.00
ADDRESS Bola SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
ADDRESS MOTORS SEE FEE SCH'
ff,f�
AOREss
SERVICE CHANGE 20.00 YJ
oo'LICENSIi1)CONTRACTORS DECLARATION TEMP.POLE 30.00
¢ v I hereby affirm 'bar I am licensed under provisions of Chapter 9 ISSUANCE DATE
wa vAi (Commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F w z Professions Code,and my license is in full force and effect ❑ ❑ ❑"I
z Om - License Class Lie.Number
9 ti w Dute t Car, .Sl.r
I- '_' - �•
a IS BUILDING PERMIT
¢ ¢ a OWNER-BUILDER UECLARA'I'ION
oa " MISC.- REFER TO ORD INFORMATION
wI-. I hereby affirm that 1 am exempt from the Contractor's License
a_ Oa' Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 ` VALUATION $/FT.
❑ Code:Any city orcounly which requires a permit mconMme L aIle" D r
m
improve,demolish,or repair an structure,prior to its issuance,also ELEC.CONTE. LIC.NO.
¢ SE ¢ p p ' Y P ELEC. I DDO.
D IL requires the applicant for such permit to file a signed statement that TOTAL PERM TO
A w sehe is licensed pursuant to the provisions of the Contractor's License
r z i
Law(Chapter 9(commencingwith Section 7000)of Division 3 oflhe
j i o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE t
r ¢ H m the basis for the alleged exemption.Any violation o(Section 7031.5 s T E CONSTR.
ate _ by an'y applicant for a permit subjects the applicant loa civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of notlmore than five hundred dollars(SS00).):
❑ I?as owner of the properly,or my employees with wages as BACK F LOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
\ their sole compensation,will do the work,and the structure is not
intended or offered for sale(See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Cade:The Comractor's License Law does not apply to art owner of
prgperty who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
+ .:. himself or through his own employees,provided 11111 Shelf "
prove-
I ments are not intended or offered for sale.IL e hcwevethebuilding GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is Sold within one year of completion,the owner-
b.
wner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
build,,,will have the burden of proving that he did not build or im-
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND eN EB Omer
❑ I,as owner of[lie properly,am exclusively contracting with ❑ ❑ Ey ❑ ❑
licensed contractors to construct the project ISec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 gSSESSOR RCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon.and who ILAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contmetor(sl licensed pursuant to SEWER-SANITAR V-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 6.00
..,on
Owner Dale WATER SYSTEM 5.00 ACC.DATE ACC.FILE N0.
` WORK E RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
�. I hereby affirm That I have a certificate of consent to self insure, ZONING ENG.SITE O.
-ry or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab CJ.
Policy N't� - 41"
O ❑ CeRTe",y,rs Qh�by f AAi ru FIRE SPRINK ENERGY T 24
+-Z Z ❑ Certified copy is fled with the city inspection division. MISC.- REFER TO ORD.
O Applican't(p��\,P Y❑ N❑ Y ❑ N❑
cc N CIS TR IP]CATE OFEXEVI TIONFROMWORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.o.
LU COMPENSATIO INSURANCE PLG.CONTR. LIC,NO. PLG.
CL Z (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
hundred dollars IS 100)or IewL
y U O .I certify that in the performance of the work for which this per, QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any mdnner so as to
O W become subject to the Workers'Compensation Laws of California.
LU Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING aLl
} W NOTICE TO APPLICANT: If,after making this Certificate of F.-
2 conform,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 or this permit shall be deemed revoked. AIR HANDLING UNIT ITO 10=C.F.M,) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNITIOVER 10,000C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 1�
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). . HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lenders aJress ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
i• • inforriation is correct. 1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby ao mriac representatives of this city to enter Spun the
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE$CH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, colts and expenses which CONST.TAX
may in any way accrue against said City in.conaeyuence of the PERMIT ISSUANCE 10.00
granting ol'this ennit MECH.CONT. LIC.NO, MECH.
TOTAL TOTAL s
hilnMoyesit Applicant/Co tractor - D'o,
Is.
INSPECTOR COPY
I