9271 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDINGAPPLICATION & PERMIT ^n
ADDRESS ZZ34i ShtYTH 'PA-14.,A BUILDING - ELECTRICAL-PLUMBING-MECHANICAL L
__
OWNER'$ - PLAN CHECK VALIDATION
NAME 2$6- QTY. ELECTRIC PERMIT FEE
• ONE
NAME AcraR OUTLETS-SWITCHES-RECEP 10.0 .00
LtC,NO ILIGHTING FIXTURES 1 .0 .00 U
fDDRESS OR's PPLIANCES-RESIDENTIAL 4.00 _
ADDRESS
PHONE PANELS 10,00 DATE OF APPLICATION
AORRCHIiECi / PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
i LIC.ND. SIGNS TRANS. 3.00
ACH .08 ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
SS
1�1U 30) EMP. METER OR POLE INS. 20.00
PPL' AN _ MOTORS SEE FEE SCH.
ADORESSI
SERVICE CHANGE 20.00
0 0 o LICENSED CON TAC
RTORS DECLARA'I'ON TEMP.POLE 30.00
a o u I hereby affirns that I am licensed under provisions of Chapter 9 ISSUANCE DATE
ww (commencing with Section 7000)of Division 3 of the Business and
¢ ,An - BLDG. ELECT. PLG. MECH
H w z Professions Code,and my license is in full force and effect. ❑
0m License Class Lie Number
H w H Dme Contmcvr
a ,: s BU DING E MIT
a a a OWNER-BUILDER DECLARATION
INFORMATION
a o a v
w g y I hereby ul fine at am exempt from the Contractor's License MISC.- REFER TO ORD
VALUATION $/FT.
F .. o J
Law for the following reason. 9031.5,Business and Professions PERMIT ISSUANCE 10.00' -
Code:Any city or county which requires a permit to construct,alter. 1
QQ¢ o inmrove,demolish,or repair any structure.prior to its issuance,also ELEC.CONTR. LIG NO. ELEC.
E m u requires the applicant for such permit to file a signed statement that TOTAL pER IT TO
d w .Int is licensed pursuant to the provisions of the Contractor's License
H to a Law(Chapter 9(commeneingwith Section 7000)of Division 3 of the
i D Business and Professions Code)or that he is exempt therefrom uad QTY. PLUMBING PERMIT FEE
¢ r m the basis for the alleged exemption.Any violation of Section 7031.5 5 5 P C N
a3 _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
01 not more than five hundred dollars($500).):
Cl I,as owner of Iry property,or my c.ployccs with wages as BACK F LOW PROTECT. DEV ICE 4.00 OCC,GROUP RES.UNITS
Irvin sole compensation,will do the work,and the structure is not
intended or offered for sole (Sea 7044, Business and Professions 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 docs such work FIXTURES-PER TRAP 5.0 0,FT.FLOOR AREA TOTALACREAGE
• himself or through his own employees,provided that such improve-
menu ere not intended proffered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IF 2.00
builder will have the burden of proving that he did not build or Im. BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RE wD .BUILDING
PB Omer
I,as owner of life property,am exclusively contracting with ❑ ❑ ❑ ❑
Ii�A7nsed contractors to construct the protect(Sec. 7044, Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor License Law does not apply
to.a owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a comractons)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10
On,Contractors License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Svc.-,B&P,C.for this I WATER HEATER W/VENT 6.00
1.1.11
T Owner .x.. �a... Date-//�.rf WATER SYSTEM 5. ACC.OATE ACD.FILE NO.
WOR :RS'COMPIiI ION DeCLnenTloN WATER.TREATING EQUIP. 5.00
I hereby infirm that 1 have a certificate of consent to self-invunc' ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No- Company
O ❑ Certified very is hertby famished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is riled with the city inspection division. MISC.- REFER TO ORD.
Q Applicant V ❑ N[] Y ❑ N[]~ Va PERMIT ISSUANCE 10
Lu C[R'I'IFICATE E TA% IOTINS PROMWORKERS' FLOOD ZONE A.L.U.C.
W > COh1PIiNSAT'ION INSURANCE PLG.CONTR. { LIC.NO. PLG.
('Phis "'linin need not be completed if the permit is for one TOTAL Y❑ ❑ [:]NY N
Z ❑
U O hundred dollars IS 100)or less.)
I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued.I shall not employ any person in any manner so as to 1't
O W become subject to the Workers'Compensation Laws of California.
a Ualc Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>_ N NOTICE TO APPLICANT: If,after..king this Certificate of Hx-
F 2 e.ption,you should become subject to the Workers'Com pensationAPPLIANCE 5.00 PLAN CHECK
provisions of the Labor Codi you must forthwith comply with FEE
U such provisions or this pennif shall be deemed revoked, AIR HANDLING UNIT(TO 10/000C.F.M.) 4.00
CONSTRUCT ION 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 performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L 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 u ELECTRIC
T certify that l have read this application and stale 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 BOILER-COMP (Over 100,000BTU)SEE FEESCH. MECHANICAL
abovementi"ned 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 way accrue"against said City in consequence of the
granting f this permit MECH.CONT. LIC.NO. MECH. '
✓ '' TOTAL .-- TOTAL
✓ Ign. APp cant/ -c r I ate -
' INSPECTOR COPY