9259 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENT]FICATI ON PERMIT NUMBER
ADDLDINGRESS 1-47 3 - APPLICATION & PERMIT ��
ADDRESS
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
s
O NER's PLAN CHECK VALIDATION
NAME 'I3Y'62@�Q24 QTY. ELECTRIC PERMIT FEE
A fee 140,44
NArvtERAcrORs OUTLETS-SWITCHES-RECEP 10.00/1.00
LIC.No. LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
OOPcmrlicT PANELS (OVER 200 AMPI 20.00 PLAN,HECK FEE P.c.No.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCHFss[NG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. .20= -
ANT's
ADDRESS MOTORS SEE FEE SCH. /J
DRESEss /
SERVICE CHANGE 20.00
0M o LICENSED CONTRACTORS DECLARATION TEMP.POLE•. r '30.00
a u I hereby affirm that I am licensed under provisions of Chapter 9 j ISSUANCE DATE
H c w (conmtencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H w z Profession.,Code,and my license is in full fore,and dl'eeL ❑ ❑ El Z o m - License Class Lie,Number
0 y- Dale Contractor
BUILDING PERMIT
¢ ¢ w a OWNER-BUILDER DECLARATION
MISC.- REFER TO ORD INFORMATION
w LL I hereby affirm that I am exempt from the Contractor'%License VALUATION
H ¢04 Law for the following reason.(Sec.7031.5,Ifusinessand Professions PERMIT ISSUANCE $/FT.
Code:Any city or county which requires a permit to construct,altcO
QwQ Q Improve,demolish,Or repair any Structure,prior to Its 14OBrI also ELEC.CONTE. LIC.NO ELEC.
a wG S, ',quires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
m m he is licensed pursuant 10 the provisions of the Contractor's License
H z r
Law(Chapter 9(commencing with Section 7000)of Division 3ofthe i.
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a3 $ by any applicant for a permit subjects the applicant ma Civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(85001.):
❑ I,as owner of the property,Or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
le
their socompensation,will do the work,and the struccon is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Rosiness and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractors License Law docs not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00
SO.Er.FLOOR AREA TOTAL ACREAGE
• himself oemployees through his own eeyeesm
,pridhd tout such improve-
mmotsare ronotintendedor mplofor sales It,however.the building GAS-EA.SYSTEM-1 INCA OUTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS EASYSTEM OVER 4 (EA.) 200
builder will have the burden of proving that he did not build or ins- GAS . - . .
- BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Ome'
0 I,as owner of the property,am exchuively contracting 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 Lanot apply
to an owner of property who buildsso w does improves does
and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for Such projects wilh a con ractngs)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.for this ,WATER HEATER W/VENT 6.00
reason
Owner nijej fl.xF WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPBNSATION DELI RATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of unx..it to self-insure. ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE N0,
copy thereof(See 3800.Lab.CJ.
policy No. Company
O O Certified copy is hereby furnished FIRE SPRINK ENERGY T 24
Z 2 0 Certified copy is Filed with t¢ city inspection division. MISC.- REFER TO ORD.
O Applicant V❑ N❑ Y ❑ N❑
cc: y CERTIFICATE OP ExEMPTiyN FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
u d 7 COMPENSATION INSURANCE FILE.CONTE. LIC.NO. PLQ j V[:] N❑ Y❑ N❑
CL Z 1'1' his section need not be completed if lire permit is for one TOTAL
hundred dollars IS 100)or I.vT
U O I certify that in the performance of the work lir,which this per QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL I- not isued, 1 shall not employ any person in any Dianner so as to
O W become subject to the Workers'Compensation Laws of Culifomia. BUILDING
a Date Applicant ALTER OR ADD TO MECH. _ 5.00
} rn NOTICE'1'0 APPLICANT: If,atter making this Certificate of Ex-
Z entption,you should become subject to the Workers Compersat ion APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U Such provisions or this permit Shall fie dwmed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION 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,Cw.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 AddleNames ELECTRIC UU
I cenily that l have read this application and nate that theabove V ENTILATION FAN (SINGLE) 4.00
information n correct. I agree ti comply with all city and county PLUMBING
ordinances and state laws relating m building co city Eion, and BOILER-COMPI3 H.P.or 100,000 B.T.U.) 6.00
hereby authm-we representatives of this city N 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 tine 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
grn of tl pen i I MECH.CONT. LIC.N0, MECH.
TOTAL TOTAL
Ignu n e o p cal/ ontrao 0
INSPECTOR COPY