9344 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
HUM1o;NG APPLICATION & PERMIT
AUORE55
3 Is BUILDING -ELECTRICAL-PLUMBING-MECHANICAL9344
NAME -qC 1z57-18i PLAN CHECK VALIDATION
QJV. ELECTRIC PERMIT FEE
0-41J CM 1 11tfit 9b9
NAMEA UT TI WITCHES 10.00/1.00 � �3..,��
0 If_ ES'1" :No LIGHTING FIXTURES 10.00/1.00 j�(/l/
ADDRESS
DDREAcroR's APPLIANCES-RESIDENTIAL 4.00 /��
PHONE PANELS 10.00 DATE OF APPLI ATION
RRCHrtECi PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00 5
ADDRESS ENc. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS. 20.00
AODRESa MOTORS SEE FEE SCH.
APPLICA
SERVICE CHANGE 20.00
w a o LICENSED CONT RACfORS.DECLA RATION TEMP.POLE 30.00
¢ U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
m a N (eontmcneing with Section 7000)'6f Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H w z Professions Code,and mydiCudse is in full force and effect.
z 0 wLicense Class V;::-/ Lic.Number E
W
o w H Datc � Contractor
a x E 'r BUILDING PERMIT
¢ a a /OWNIi R-BUILDIiR DECLARATION RA'PIOR
¢ w sa ./ INFORMATION
A 3 LL N Sw lot th Rohn that I .m exempt from the Contractor's License MISC.- REFER TO ORD
LLo J 'L'uw lot the following rcuson.lsec.7031.5.Bnsinessand Professions PERMIT ISSUANCE 10.00 VALUATION 8/FT.
� - Code:Anycity orcounty which requimsapennitioconstruct,,Iter, �f
¢¢ 2O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. O'er
in - O LL rey vires the applicant for such permit fo file a signed statement that TOTAL
F
m w he is licensed pursuant to the provisions of the Contractor's License - MIT TO
Law(Chapter 9(commencing with Section 7000)ofDivision 3 of the
¢ ao Business and Professions Code)or that he is exempt thercliom and QTY. PLUMBING PERMIT FEE
ihispusis for the alleged exemption.Any violation of Section 7031.5 ST E C N r .
E. by airy applicant for,permit subjects the applicant oacivil penally ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not a than five hundred dollars(55001J:
❑ I,as per of the property,or my employees with wa6es as BACK F LOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole cuirmen'Hum,will do Ibe work,and the structrvo is not
intended or ofl'ei'bd for sale (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code The Contradtor'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 or through his own employees.provided that such innprove-
meals are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year ofcompletion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or inn- BUILDING USE
5
prove 1for,aso of sale J' IND CON PB Other
❑ wnernee
of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00
licensed
as o
contractors to construct Om 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 contracts
owner of properly who builds tr thereor.puand who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
(lie Cont for such projects with a amlmctortal licensed pursuant to
the Contractor's License Law. SEWER-SAN ITAR V-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ Iam exempt under Sec. ,B.&BC.for this WATER HEATER W/VENT 6.00 -
reason
Owner DateWATER SYSTEM 5.00 ACC.DATE ACG FILE NO,
J W KIiRS'COMPIiNSA'I[ON DECLnRATIo � ,,. WATER TREATING EQUIP. 5.00
I hereby affirm flint I have a cerificale of consent to'sel&insure' ZONING ENG'SITE NO.
or a certificate of Workers'Compensation Insumriee'or a certified
copy thmeof(Ste.3800,Lab.C.).
Policy No. Company
O O Certified copy is hereby t nnlshed. FIRE SPRINK ENERGY T 24
Z Z O Certified copy'fs filed with tiro city inspection division.
p: Q Applicant MISC.- REFER TO ORD. Yo N❑ Y ❑ NE]
a - ' PERMIT ISSUANCE 10.00
LU CIiRTI FICATIi OF Ii0PTIPROM WORKIiNS' FLOOD ZONE A.L.tI.C.
W > COh1PENSA1
l'0�INSURANCE PLG.CONTR. LIC.NO. PLG.
CL C1 (This action need not be completed it the permit is for one TOTAL V N� Y IN
hundred dollars(S 100)or leu.)
U 0 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
U_ I- mil is issued,I shall not employ any person in any manner so as to
O become subject to the Workers'Compensation Laws of California.
S.
W Ihde. Applica°t ALTER OR ADD TO MECH. 5.00 BUILDING
>_ ED NO'I'ICF '1'O APPLICANT If,after making this Certificate of Fx-
F. ?
Sorption,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 decnned revoked AIR HANDLING UNIT(TO 10/OODGF.M.) 4.00
r 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,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct.I agree to comply with all city and county PLUMBING
ordinances and state laws relating o building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authoritc representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)S EE 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 PERMIT ISSUANCE 10.00 CONST.TAX
may in any way acc against said 'ty in consequence of the
graining oft Yp t MECH.CONT. LIC.NO. MECH.
\ TOTAL TOTAL
XSig a •o A nplican nine r ate 4 1
INSPECTOR COPY