9443 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
ilh BUILDING APPLICATION & PERMIT
ADDRESS _ 9 4 4 3
D NN I/ LfS BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
0 ry R5 S PLAN CHECK VALIDATION
NAME ELECTRIC PERMIT FEE
PAOTO P PHONE
CONTRACTORS OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME �S CK
F L1C.NO, V / 42% LIGHTING FIXTURES 10.00/1.00
CONTRACTOR
ADORES, APPLIANCES-RESIDENTIAL 4.00
A
Q PHONE ,24VPANELS 10.00 DATE OF APPLICATION
AHCHI T PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENc' SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
ADDRESS rs MOTORS SEE FEE SCH. /1 -
SERVCCE CHANGE 20.00
,00 LICENSED CONTRACTORS DECLARATION TEMP POLE 30.00 ( j C-I
< o U I hereby affirm that.)am licensed under provisions of Chapter 9 ISSUANCE DATE
w a N (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F w z License Cl.Code.and my license is in full force and effect. ❑ ❑ ❑
Z O m,- License Class r/D Lic.Number `n
9 I- Dale Contra.for
Ys ILUIR DECLABA�ixr"91 BUILDING PERMIT
C OWNER-BU
INFORMATION
wo a ° r°' REFER TO ORD
u I hereby Tallinn (hut I am exempt from the Contractor's License MISC.- , VALUATION SIFT.
w• .. 04 Law for the following teaser.(Sec,7031.5.Basinessand Professions PERMITISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
Qimprove,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
DLL requires lire applicant for such permit to file a signed statement(hal TOTAL PERMIT TO
w m he is licensed pursuant to the provisions of the Contractor's License L
Hzi Law(Chapter 9(commencing with Section 7000)of Division 3 oftheGLC G7-
a Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
oo 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-DflAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollar,(S500L):
❑ I,as owner of the property,or my employees with wages as BACK FLOW 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 (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,GOND. 5.00
Code:The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP - 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
merits!of through his own Corbyor sale.provided however,
such ibuildi o-
musts aro through
rinlandis or offered sees,provided that such
building GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, the owner GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
huilder will have the burden of proving that he did not build or im-
p"we for pugmvc.1 cdc.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON EB Omer
, ❑ I,as owner of the property,ant oxc mwily emnrxcting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor'sLicense Law docs riot apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
^ contracts lorsuch projects with a contractogs)licensed pursuant to SEWER-SAN V-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam escmpt mhdcr Sec. ,lie&I'.C.for this WATER HEATER W/VENT 6.00
L rea,un
Owncr Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO. `
WORK ERS'COIMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure, TONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
.copy t hcomf(Sec.3804 Lab J.
Policy No.r_"n.3®dl8t /z.�a�yvGl_
O ❑ CCr11 led Cupy is hereby furnished FIRE SPRINK ENERGY L]4
Z ZT ❑ Cerlif copy Is ilcc uh the 'y invpcclion division. MISC.- REFER TO ORD.
O/ App l ic;utl' Y[:] NE] Y E] N[:)
CERTNICAIF OF EXEMTION PROM WORKERS' PERMIT ISSUANCE 10.00 FL000 zoNE A.L.u.c.
til > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O (This section need not be completed if the Pe nn it is for one TOTAL v❑ N❑ v ❑ N❑
D Z hundred dollars($100)or less.)
U O 1 1 certify that in the performance of the work for which this per, OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL l- shit is issued,I shall not employ any person in any manner so as to
0 U become subject to the Workers'Compensalion Laws of California. BUILDING
a Date Applicant ALTER OR ADD TO MECH. 5.00
} W NOTICE-TO APPLICANT: If,after making this CeRificsto of Fx-
♦- Z emption,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 lir this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.NL) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
- the pert097, oremuMICROFILM
nce of the work for which this permit is issed(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Linder',Name
Aldo HEATING UNIT(OVER 100,000 B.T.U.)Leodcr�s Addmx, 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 aatbrize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-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,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
granting of this per iL MECH.CONT. LIC.NO, MECH.
TGTAL TOTAL
App¢ant/CoActor Dale
INSPECTOR COPY