9207 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT 1 DENT[FICATION
PERMIT NUMBER
POOR APPLICATION & PERMIT
POOR �j///�i1TOls+9-�;W91191,1V 1A5 / BUILDING -ELECTRICAL-PLUMBING -MECHANICAL 9207
NER' PLAN CHECK VALIDATION_
"AmE�G/y �/A1 QTY. ELECTRIC PERMIT FEE
• A I HONE37 IIAIW
CONTRACTORS
/ NAME PUTLETS-SWITCHES-RECEP 10.00/1.00
_;7446 LI C.NO. ? - LIGHTING FIXTURES 10.00/1.00
...///
ADDRESS APPLIANCES-DDREs PPLIANCES-RESIDENTIAL 4.00
CONTR A
(' PHONE PANELS 10.00 DATE OF APPLICATION
ilfC ITECT
OR / PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.N0,
ENGINEER GG
uc.NO.
SIGNS TRANS. 3.00
ADDRESS ErvG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
"f2, EMP.METER OR POLE INS. 20.00
APDL cAN MOTORS SEE FEE SCH.
ADDRESS I V
/ / - SERVICE CHANGE 20.00
o o LICENSED CONTRACTORS DECLARATION TEMP,POLE 30.0
a v u I hereby affirm that I um licensed under provisions of Chapter 9 ISSUANCE DATE
(conuneacl ng with Sc2tion 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
rD z Professions Code,ion my license is in full force and ffect.
z 0 License Class- �Lia.NumberH��9� El
❑ ❑
0 z a Dolc��-/_���Conlmctortsy_ Q
¢ x s .a - r/� "'T/V BUI DING PERMIT
¢ S, w OWNIi R-B MILDER DECLARATION INFORMATION
wSt a vHi 1 hereby affirm that 1 am exempt from the Contractor's License MISC-- REFER TO ORD
LLov, Law for the followingreason.(See.7031.5,Business and Professions PERMIT ISSUANCE ,1 VALUATION S/FT.
Code:Anycity orcounty which requires a permit to construct,alter,
ac w Q SE O Improve,demolish,or repmr any structure,prior to Its Issuance,also ELEC.CONTR. LIG NO. ELEC.
D , requires the applicant for such permit to file a signed statement that TOTAL I
PERMIT TO
E
m w he is(Chapter
licensed pursuant ri the provisions of the )ofDivtoh License
F z a Law(Chapter 9(commencing wish Section 70001 of Division Sof the
4 D Business and Professions Code)or that the is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ I- o the basis for the alleged exemption.Any violation of Section 7031.5 1 STORIES TYPE CONSTR.
or e' by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEV ICE 4.00 OC f P- R
their sole compensation,will do the work,and the structure is not
ES.U"gr5
intended or offered for sale (Sec. 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 does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself re through his Awn employees,fors,provided that such ire building
mems ore not through
intended hisow oemployeesale.lf,ed that such
building GAS-EA.SYSTEM-l1NC.40UTLETS 6.00
or improvemmtit 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 Aid not build or air
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ I,as owner of the property,anti exclusivCly contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,BusinessLAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Comractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA,) 1.00
contracts for such projects with a contractoos)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ lanl exempt under See .B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Over" Date WATER SYSTEM 5.00 ACC.DATE ACC,FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
I hereby otirm that 1 have a certificate oI consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Worknri Compensation Insurance,or a certified
copy thcrcof(Sec.3800,Leb.C.).
Policy No.q,.;.:6a6,Company )
142
❑ CCrii6ed copy'is hereby'far FIRE SPRINK ENERGY T 24
Z Z ❑ Certified^opy is RICO wi 1 rn cay lospection division.
f �. MISC.- REFER TO ORD.O Applicant .➢ Gt'� V ❑ N❑ V ❑ N❑
ir = 21:RTIN ATEOI?EXEMPTION-MPT�ION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LL > COAIPFY ATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL (11n, section need nod be completed if the permit is for one TOTAL Y EJ N❑ V-❑ N❑
Z hundred dollars(5100)or less.)
U O I certify that in Ole pedbourncc of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall nm employ any person in any manner so as to
0Ubecome subject to lire Workers'Compensation Laws of Callomia.
y [)arc Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} m NOTICE 'ID APPLICANT: If,after conking this Certificate of Ex-
F Z cmption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you aunt forthwith comply with FEE
CJ such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONS'T'RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10)DOOC.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 Ilia work for which this permit is issued(Sec. MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
, HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC r
Lender Address
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
•
inter....lion is correct I agree to comply with all city and count, PLUMBING
ordinances and state laws rending to building construction, and 130ILER-COMP(3H.P.or100,000B.T.U.) 6.00
hereby authorize 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 CONST.TAX
may in any way accrue Inst Said City in consequence of the PERMIT ISSUANCE 10.00
an g f This permit, MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
ign e h n tractor Date !� �,
INSPECTOR COPY