9314 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 9314
DwNER'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
CONTS fGHR.ta� •,QM'610NE / /J
NAmERAcroRs UTLETS-SWITCHES-RECEP ]j,Qfll1.00 f
CO uc.No. LIGHTING FIXTURES 11.00
co
ADDRESS roR's G�GD l. o PPLIANCES-RESIDENTIAL 4.00
'
r HONE PANELS 10.00
t"' DATE OF APPLICATION
ARCH E T I PLAN CHECK FEE P.C.NO.
OR _ PANELS (OVER 200 AMP) 20.00
ENGINEER
ua NO ,�' SIGNS TRANS. 3.00
A RCH.OR ENG. PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00
APPLICANT s ZIP EMP.METER OR POLE INS. X00
ADDRESSDREss .MOTORS SEE FEE SCH. -�
SERVICE CHANGE 1 20.00
Foo LICIiNS1iU CONTRACTORS DECLARA'PION TEMP.POLE 30.00
to u U I hereby affirm that 1 ant licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and
a BLDG. ELECT. PLG. MECH.
F w zy Professions Code,and my license is in full force and
efeeff--feeccttf('-- ❑ ^
2 o w - License Class C. Numbe,39v `� 1,2
o 0 - ate Contractor
a y f (0�NN5 BUILDING PERMIT
Ica O :R-BUILUIiR DFCL �AffO
a o a UISC.- ~+ REFER TO OR
INFORMATION
w ; 1 hereby at Iirm that 1 am exempt from the ContCtractor's License
rn VALUATION
F LL o j Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00 'W 6
m� hi
Code:Any City wch requires a permit to construct,alter,
a ¢ a22 improve, or repair any structure,prior to its issuance,also ELEC.CONTR. LICWO. ELEC. ou
DLL requires the applicant for such permit to file a signed statement that tl TOTAL PERMIT TO
K
m he is licensed pursuant to the provisions of the Contractor's License
F a i Law(Chapter 9(commencing with Section 7000)of Division 3 oftbe ,1�
a Business and Pmficscions Code)or that he is Cxcmpt therefrom and OTY. PLUMBING PERMIT FEE ELF 7 /�✓�'4" /7t
H o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant fora permit subjects the applicunn.aciviI penalty ALTER-DRAIN&VENT-WATER IEA.) 5.00
of not more than five hundred dollars fS500).):
❑ L 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 trot apply to an owner of
property who builds or improves thereon,and who does such work 11FIXTURES-PER TRAP 5.00SO.FT:FLOOR AREA TOTAL ACREAGE
• himself or through his own cmphiyces.Provided that such impnr.e. .
Rents are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.4 OUTLETS 66-00
or improvement is sold within one year of Completion,the owner- GAS EASVSTEM-OVER 4 (EA.) 200
builder will have the burden of proving that h - .• . .
e did not build or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB oma,
❑. I,as owner of the property,am exclusively 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's License Low dries not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts lin such projects with a contmctor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/
the Contractors License Law. -Sto 110 TRACT NO. PARCEL NO.
❑nlam exempt under Seo. ,e.&RC.for tllis WATER HEATER W/VENT 6.00
re
Owner Dstc WATER SYSTEM 5.00 ' ACC.DATE ACC.FILE NO.
WORKERS'COMPI:NSA'TON DECLARATION WATER TREATING EQUIP. 5.00
I hereby atGrn that I have a certificate of consmd to Self-inure. ,. ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No. Company F /.- ej Pei.•(, .
O 0 Certified copy is hereby.fir ed. FIRE SPRINK ENERGY T 24
Z'
❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
Q Applicant Y❑ N❑ Y ❑ N❑
w Cli 'fu']C.ATI:Ob EXEM PITON FROM WORK h RS' PERMIT ISSUANCE FLOOD ZONE A.L.U.C.
LLI > COMPE.NSWION INSURANCE PLG.CONTR. LIC.No. PLG.
d O (This section need not be completed if the permit is for one TOTAL O rN Y❑ N[_ Y❑ N❑
D Z hundred dollars(SIDE)or less.)
U O I certify that in the performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
U_ I- mit is issued,1 shall not employ any person in any manner so as to
Ow become subject to the Workers'Compensation Laws of California. BUILDING
M. Date Applicant ALTER OR ADD TO MECH. 5.00
} to NO'1'ICI7 10 APPLICANT: If,after making this CeRib"Ic of ISx-
F ? 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 or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MCF.M.) 4.00
CONSTRUCTION L17NDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performunce of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATI NG UNIT(OVER 100,000 B.T.U.19.SO ELECTRIC f/Pi
Lender's Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 ,L.
information is ivRect. I agree to comply with all city and county PLUMBING 0-p
ordinanacs and state laws relating to building construction, and BOILER-COMP(3H.P.or100,000B.T.U.) 6.00
hereby auUlorite representatives of this city to cmc, upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL )
above-mentioned property for inspection purpo>•L•s. N/
(Wc) agree to save, indemnify and keep hurniluss the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against Said City in consequence of the PERMIT ISSUANCE 10.00
granting.fthis permit. MECH.CONT. LIC.NO. MECH.
SigneTOTAL �3 f� TOTAL
LT ppant/ onlractor )u c
INSPECTOR COPY '