9194 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BDI LDING APPLICATION & PERMIT
ADDRESSS10
9194
C-M 13CYL DIZ BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'5 PLAN CHECK VALIDATION-
*AMC
ALIDATIONNAME OTY. ELECTRIC PERMIT FEE
• ` o PHONE
ARACrDR$
NMEOUTLETS-SWITCHES-RECEP 10:00/1.00 db
CCDIECV,CI C-tee RIiff,E.N°. lljE,/ LIGHTING FIXTURES 1000/1.00
CONTRACTORS
-RESIDENTIAL 4.00
ADDRESS
I PPLANCES
ZQMbQ&J fJaI10PHDNE Zpp&G-13690 .n•
PANELS 10.00 DATE OF APPLICATION
ARCHITECT' PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
°R
ENGINEER
uc.No. SIGNS TRANS. 3.00
ADDRESS ENc' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP. METER OR POLE INS. 20.00
APPLICANTS
ADDDRESSDRESSMOTORS SEE FEE SCH.
/
SERVICE CHANGE 20.00
o w o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
CE v u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y Z w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG, I MECH.
F w Z Professions Code,and my license is in full force and effect
Z 0 w - License Class r O Lic.Number -1,St r_T3� ❑ ❑
2 Z H w Date r.� /_8Y ContractorgppH9tly.B-
a Y E CbT- RPC "iM BUILDING PERMIT
w
OWNER-BUILDER DELLA RAT@IO\ INFORMATION
w0 LL H 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION
i- L_ O< Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 rN
Cade:Any city orcounty which requires a permit to crosa,act,alteq �- _
< improve,demolish,or repair any structure,prior 10 its issuance,also ELEC.CONTE. LIC.NO. ELEC.
A - IC requires the applicant for such permit to file a signed statement that TOTAL C" PERMIT TO
w m he is licensed pursuant to the provisions of the Contractor's License -
Hzi Law(Chapter 9(commencing with Section 7000)of Division 3oftire EL�L7
a Business and 1'mfssions Code)or that he is exempt Hhcrefnnn and GTV. PLUMBING PERMIT FEE
the basis fur the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. r
by any applicant for u permit anquyetsthe applicmatoacivilpearlty ALTER-DRAIN -WATER IEA.) 5.00
of not alone than live hundred dollars(55007.1:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 DCC. OUP RES.UNITS
their sole compensation,will do tire work,and the Structure is not
intended or offered fur 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 TOTAT ACREAGE
• himself or through his own employees,provided that such improve-
u
menare ,at intended or offered for sale.If,however,the building GAS-EA.SVSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner, GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RE5 d CON PB Other
❑ 1,as owner of the property,am exclusively contmcliag 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's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts for such projects with a contractots)licensed pursuant to SEWER-SAN V-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
\ ❑ I um exempt under Sce. .B.&P.C.for this WATER HEATER W/VENT 6.00
� naum
Owner Date WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO.
WORKHRS'COMPHNSA'f10N DECLARATION WATER TREATING EQUIP, 5.00
1 hereby affirm Hurt I have d certificate ofconsent 1.svlGinnue' ZONING ENG.SITE NO.
or a certificate al'Workers'Compensation Insurance or a certified
Tcopy thereof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby famished FIRE SPRINK ENERGY T 24
Z 2 ❑ Certified copy is filed with the city inspection division.
� MISC.-
REFER TO ORD.
Y ❑ NEIY ❑ N❑
O Applicant T) C Ii RI'11:I CA'f1!01'IF Lid PTI ON FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LLI > COMPENSATION INSURANCE. PLG.CONTR. LIC.NO. PLG.
0- Z( 'this section need not be completed if the permit is for on. TOTAL Y❑ NE] Y E] N❑
hundred dullars(SI00)or IessJ
U O I certify that in the performance of the work for which this pery GTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any person in any manner so as to
O w became suhjeU to the Workers'Com ensasion Laws of CaLfonhia.
y Dete's'An ABrA Pplh°am 'f? ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOI 1: 10 APPPLICAN f: If,3"Y(e a ung thprl oral Irate of Lx'
F Z_ enhplion,you should become subjeet to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or Dhis penin[shall be deemed revoked. AIR HANDLING UNIT(TO 10)000C.F.M.) 4.00
CONSTRUCTION LENDING AGI7NCY AIR HANDLING UNIT(OVER 10MIC.EM.) 6.00 SEISMIC FEE
1 hereby alfirnh that there is a construction lending agency fur EXHAUST HOOD(WITH DUCT) 5.00
itI. ....brilliance of[lie work for which this permit is issued(Sec. MICROFILM
3097,Ci,CA HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lendch Nam, HEATING UNIT(OV ER 100,000 B.T.U.)9.50 o
Lender's Address ELECTRIC T/
I Certify that I have read Ihisdpplication and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city and county PLUMBING
ordinances and state laws relating 10 building construction, and BOILER-COMPI3 H.P.or 100,0008.T.U.) 6.00
It authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mcrnianed property for inspection purposes.
(W4) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs andexpenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in cons,
ounce of the
granting oftlhis permit. MECH.CONT. LIG NO. MECH.
_ TOTAL TOTAL
\ nal r of nl on.actor Dale
INSPECTOR COPY