9442 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
DAPPLICATION & PERMIT
A9442
ADDRESS
C- BUILDING - ELECTRICAL-PLUMBING -MECHANICAL
OWNER r
PLAN CHECK VALIDATION
NgME
• QTY. ELECTRIC PERMIT FEE
PHONE
CONI�C NAME4 D i ( OUTLETS-SWITCHES-RECEP 10.00/1.00
l� IuC.No. LIGHTING FIXTURES 10.00/1.00
co ACTOR
ADDRESS PPLIANCES-RESIDENTIAL 4.00
PHONE V4 / V PANELS 10.00 DATE OF APPLICATION
OR
PANELS 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
uc.No. SIGNS TRANS. 3.00
ARCH.
DD fes END. PERMIT CIRCUIT 5.00
SPEPERMIT VALIDATION
ZIP EMP. METER OR POLE INS. 20.00
ADDRESS rs MOTORS SEE FEE SCH. n �J
SERVICE CHANGE 20.00
6 i
o o LICENSED.CONTRACFORS DECLARATION TEMP.POLE 30.00
U w I hereby affirm that 1 am licensed Linder provisions of Chapter 9 ISSUANCE DATE
H 1 h (commencing with Sector 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r-o Z Professions Code,and medic se is in full force and effect.
z 0 u, - .icense Class P Lic.Number rr ti6�f�(t/ ❑
0 m w Bate Contractor
a x s BUILDING PERMIT
¢ ¢ a • OWNER-BUILDER DECLARATION
A oa U INFORMATION
w 3 LL I- Thereby affirm that 1 am exempt fmm the Convantor's License MISC.- REFER TO ORD
uoJ Law for the following reason. 7031.5.Businessand Professions pERMIT ISSUANCE 10.00 VALUATION $/FT.
� - Code:Any city or county which requiresaperrai IrL.mlruct,alteq
w rove,demolish,Or re air an structure,prior to its issuance,also ELEC.CONTR. LIC.NO.
IS a 0 .imP p' Y Pi ELEC.
c¢ requires the applicant Cor auch permit to file a signed swicurcrit that TOTAL PERMIT TO
n w m" he is licensed pursuant to the provisions of the Contractors Licen sc
F A- i Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe �L 8
a Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE lT�
i 0
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 (EA.) 5.00
,)feet mom than live hundred d.IWms(55001.):
0 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
an't their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale(Sec. 7044, Business and Profession DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 - SET FT FLOOR AREA TOTAL ACREAGE
hi• Hnds are not intended
ownemred for sale.
11,however.
the
improve- GAS-EA.SYSTEM-1 INC-4 OUTLETS 6.00
mems are not intended or offered for sale.If,ed that a the building
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
RES IND CON PB Other
prove 1,as owner
of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ L as owner Of the property,he exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractorIncoContractor's
ontrathe project(Sec. 7044,otaply LAWN SPRINKLERS-1 INC5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Conbuildsr s License Law Joos not apply
to contracts
.caner of property who builds tr improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
con COnU.orsuehceneots Lwithu mntructoty sl licensed pursuant to SEWER-SANITARY-STORM EA.200ft 10.00
the Cdn Vact.i s License Law. / TRACT NO. PARCEL NO.
❑ tutu exempt under Sec. ,R.&P.C.lilt this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 - ACC.DATE ACC.FILE NO.
WORK F-RS'COMPENSATION D17CLARA'I'ION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure. ZONING ENG.SITE NO.
Lir a certificate of Workers'Compensation Insurance,or a ccrtificJ
copy thereof(Sec.3800,Lab C.).
Policy No. Company -k}�'�
O ❑ Cert flied copy is hereby form bed. RE SPRINK ENERGYTTa
z•Z 0 Certified copy is filed with the city-ins q� ty�w8vN.'r
O Applic:mt MISC.- REFER TO ORD. Y❑ N❑ Y ❑ No
CrN CE FICA'I'-OIr EXEMPTION FROM WORKERS. PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LLI > COMPIiNSATION INSURANCE PLG.CONTR. LIC.NO, PLGCL 0 .
CL Z (This senitin need not be completed if the Permit is for one TOTAL Y❑ N❑ Y [:] N❑
Hundred dollars IS 100)or Ices.)
U O I certify that in the purl'oraience o1'the work for which this pct- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
I F mit is issued,I shall not employ any person in any manner so as t0
Ow becomes object to the Workcri'Compensation Lawaof California.
Dam Applicant BUILDING
>_ y NOTICE: TO APPLICANT': If,after..taking this Certificate.f Ex. ALTER OR ADD TO MECH. 5.00
F Z emption,you should bveonm 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(TO 10MC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10PMC.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 the work for which this permit is issued(Sec. MICROFILM
I 3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)Lndclh 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 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 authorize representatives of this city to enter upon the
above mentioned property for inspection purposes. gO1LER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgnrentx, costs and oxpenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
gramlingofttispermit. �.1 MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Si r p an[Contract. ate- '
INSPECTOR COPY