C9411 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FICATIx PERMIT NUMBER
AI �0 APPLICATION & PER 8411
AD08OOR E55SS �-�"�
&gaz .bl�Y ` BUILDING -ELECTRICAL-PLUMBING -MECHANICAL
WHETQ�
•
NpI/T// G�7'�/ D6./J�R,qj /J( LAN ECK VALIDATION AME DTV. ELECTRIC PERMIT FEE
Q FNNE
rNAICONTRACTORS� y � 12
UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO. LIGHTING FIXTURES 10.00/1.00
coNTRAcro sAPPLIANCES-RESIDENTIAL
/ ADDRESS 4.00
Q PHONE PANELS 10.00 DATE OF APPLICATION
OPRCw ECT PANELS (OVER 200 AMN 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
..uc.No. SIGNS TRANS. 3.00
ADDRESS ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
AMOTORS SEE FEE SCH.
ADDREDDRESSS
,4.A SERVICE CHANGE 20.00 (,
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 91//1
Fi W I hereby aff rm that I am licensed under provisions of Chapter 9 a ISSUANCE DATE
a w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H D z Nufessiars Code,and my license is in ee
full force and of l. ❑
0o Z m o License Class Liu.Number
Z Date Contrnctor
BUILDING PERMIT
¢ 0 i
OWNER-BUILDER DECLARATION INFORMATION
w3 y 1 hereby affirm Thal 1 am exempt from the Contractor's License REFER TO ORD
LLoaLaw for the following reason.(Sec.7031.5,Businessaad l'oue,ions VALUATION $IFT.
m PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter, C.
rt2 < improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
o ¢ requires the applicant for such permit to file a signed statement that TOTAL
n w m vi he is licensed pursuant to the provisions of the Contrnctor s License PERMIT TO w.
HZQ
Law(Chapter 9(comnencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he is exempt thereGom and CITY. PLUMBING PERMIT FEE eE N9 7 ill Afad.
¢ F p the basis for the alleged exemplum.AnY viola)on of Sect ion]031.5STORIES TYPE CONST R.
u3m by any applicant for a permit subjects the applicant on 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 FLOW PROTECT. DEVICE 4.00
their tocompensation,will da the work,and the stmcluic is not OCC.GROUP REB.UNITS
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 50.FT.FLOOR AREA TOTAL ACREAGE
%^• himself re through his own employees,fors,provided that such improve-
ments mselfonot intended onempoyees, le.Iided that suhe...poing GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 (EA) 200
builder will have the burden it ousin,(hat he did not build or int - . - . .
- BUILDING USE
RES
P....for purpose of sale.). IND CON PS Other
INDUSTRIAL WASTE INTER. 30.00 ❑ E] El El ❑
Cl
as owner of the properly, exclusively contracting with
licensed contractors to construct thehe project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to antr owner of property who builds tr improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
+ controns for such ceneLwithucmvradorlsl licensed Pursuant to SEWER-SANITARY-STORM EA.200ft/10.60
the Contractor's License Law. TRACT NO. , PARCEL NO.
❑ lam exempt under Sec. ,tl.dP.C.far this WATER HEATER W/VENT 6.00
r reason
Owner Dat, WATER SYSTEM 5.00 Z
OCC.DATE ACC.FILE NO.
t 1
W'ORRI-RS'COMPENSA'I'ION DECLARATION WATER TREATING EQUIP. 5.00 f 4
I hereby affirm that 1 have a certificate ofconsent to sell-insure. } '.ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy nlmreof(Sec.38Co portLab ).
Policy N Company-.....
❑ Certified copy is hereby furors •d _ FIRE SPRINK ENERGY T-24
Z Z ❑ Certified 'py is filed w'rt he city inspection division. 1
- OApphc ._ ,t A MISC.- REFER TO ORD. I v❑ N❑ v ❑ NE3
rnT (?:R71 ATh OF EXFMPTIONP bfl Rkf:R6'�• PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C./
^. LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. I
CL Z This section teed not be completed if the permit is for one TOTAL Y[:] N[_ Y LJNE]
hundred dollars(S 10()or less.)
U O 1 certify that in the performance of the work for which this per CITY MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
0 L) become subject to the Workers'Compensation Laws of California.
a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING (�{�
In NO]'ICI: 'TO APPLICANT: It,after making(fits Cenil'Icxte of Ex-
F 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
r- U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONST RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 1ODMC.F.M.) 6.00 SEISMIC FEE 0 �
1 hereby affirm mm 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.). HEATING UNIT(TO 100,000 B.T.U.) 6.00
Lender's Name EATING UNIT ER 100,000 B.T.U.)9.50 I ELECTRIC -+
Lender's Address H ,
I certify that I have read(Misapplication and state that the above VENTILATION FAN (SINGLE) 4.00 j
v information is correct. I agree to comply with all city and county PLUMBING
ordinances and stale 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 100,000 BTU)SEE FEE SCH. I1� MECHANICAL
above mentioned properly 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 anway accrue against said City in consequence of the PERMIT ISSUANCE 10.00
graullin drt ¢permit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL �
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INSPECTOR COPY --'•,7
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