C9504APPLICANT TO FILL'IN INFORMATION WITHIN RED LINES - USE BALL POINTfPEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION &PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
BUILDING
A9504ADDRESSDRESS
O E 'sT
NAME
/,ti / GGIO h 636
PTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
3 c2 3 1 „ (j
CONTACTORS
UTLETS-SWITCHES-RECEP 10.00/1.00 j
A L 41 J LIC 0
S
&IGHTfiNG FIXTURES 10.00/1.00 O
E NrR cross
ADDRESS
M p
AP 4.00
/'
` LG ((,.0 O✓ PHONE l� O�
PANELS 10.00 It
DATE OF APPLICATION
ARCHITECT
O
OR
PANELS (OVER 200 AMP) 20.00 ) 0�
PLAN CHECK FEE P.C. NO.
NGINEER
T,v /} LIC. Na.
SIGNS TRANS. 3.00
ADDRESS G.
SPECIAL61RCUIT 5.00
PERMIT VALIDATION
// AA i ez % ZIP p %�
EMP. METER OR POLE INS. 20.00
APPLICANT'S
ADDRESS
MOTORS SEE FEE SCH.
f
/ l'
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
TEMP. POLE 30.00
1 hereby affirm that I Tun licensed under provisions Df Chapter 9
(cmeatencing with Section 7000) of Division 3 of {IdBusine'� lic
Professions Code, ul nIy ense ix in full force i ndce
1 't
License Class Lle. Number �
ISSUANCE DATE
B G.
ELECT.
PLG, MECH.
❑ ❑
' Uotc Cmltrucfo i' `ARK'
BUILDING PERMIT
INFORMATION'
• OWNER -BUILDER UIiCLARAIION
I hereby all'irnt that I um exempt from the Contractor's License
Law for the following reason. (Sea 7031.5, Businessand Professions
Code: Any city orcounty which requires a permit to construct, alter,
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
MISC.- REFER TO ORD
PERMIT ISSUANCE 10.00 �Q �-
VALUATION
^ �^
.t /FT.
ELE CONTR. LIC, NO.
/
(O�f, i I ee _t
ELEC.
TOTAL -
`e-0
Q PERMIT JPU
'
QTY. PLUMBING PERMIT FEE
DRIES
TYP CONSTR.
the basis for the alleged exemption. Any violation of Section 7031.5S
by any applicant for permit subjects 500).licantoo civil penalty
of not more than five hundred Dollars (5500)J :
. .
ALTER-DRAIN-WATER(EA) 500
Cl I, as owner of the property, or my employees with wages as
their sole compensation, will do'Ihe work, and the structure Is not
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 5.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work
himself or through his own employees. provided that such improve-
memsarenotintendedorofferedforsale. If, however, the budding
FIXTURES - PER TRAP 5.00
SO. FT. FLOOR AREA
TOTALACREAGE
GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, the
builder will will have the burden of proving that he did not build or im-
prove for purpose of sale.).
❑ 1, as owner of the properly, am exclusively contracting with
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
4 BUILDING USE
REs -IND PB Ohara
El ED ❑ ❑
INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: The Contmetor's License Law does not apply
to an owner of property who builds or improves thereon, and who
contracts for such projects with a contractor) s) licensed pursuant to
lho Con tractors License Law,
LAWN SPRINKLERS- 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSO RCeL NO. "
1
SEWER -SANITARY -STORM EA. 200tt/1 00
d P
TRACT NO.
PARCEL NO.
❑ 1 ant exempt under Sec. ,BAP,C. for this
WATERHEATER W/VENT0 J ti' ' 6.00
reason
I
Owner Date
WATER SYSTEMI 's's '•a5.00
ACC.DATE
SACC. FILE NO.
�1\ WORKERS'COMPENSAIJODECLARATION
r.'WATER TREATING EQUIP. ((f S 5.00
I hereby affirm tllat have a tit l¢Otcofcun n elf -insure.
}� sc or
or a certificate to of Worke' f/�Fnpansot inn Incur , or a certified
-- sv'
^+n `v
ZONING
ENG. SITE NO.
copy thereof (Sec. 3800, I��'(i C.1.
Policy No,t Cogrpany
FIRESPRINK
Y ❑ N❑
ENERGY T 24
v ❑ N❑
❑ Certified copy is reby'furnlshed.
❑ Certified Copy Is filed with the ci n : emion divisi
Applicng <-
MISC.- REFER TO ORD.
CERTIFICATE 017 EXENIIII' ON 17RONLw�I RK IRS'
PERMIT ISSUANCE 10.00
FLOODZONE
A.L.U.c.
COMPENSATION INSURA.l
(This section need not be completed if the permit is for one
Y ❑ •N ❑
Y ❑ No
PLG. CONTR. LIC. NO.
PLG.
TOTAL
hundred dollars (S 100) or less.)
1 certify (hat in the performance of the work for which this per-
,mit is issued, I shall not employ any person in any manner so as to
become subject to the Workers' Compensation Laws of California.
Uatc APplicunt-
CITY [/ MECHANICAL PERMIT FEE
FEE SUMMARY
'
BUILDING
ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
emption, you should become subject to the W'orkeli Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
APPLIANCE 5.00
PLAN CHECK
FEE I
AIR HANDLING UNIT (TO 10,000CF.M.) 4.00
AIR HANDLING UNIT (OVER 10=C.F.M.) 6.00
SEISMIC FEE
r
CONSTRUCTION LENDING AGENCY
EXHAUST HOOD (WITH DUCT) 5.00
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec
3097, CN.CJ.
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
Addo
Lender's AJdress
HEATING UNIT (OVER 100,000 B.T.U.) _
LELECTRIC T(A/ 7
I certify that I [lave read this application andstate that the above
VENTILATION FAM(SINGLE) 1J U 4.00
-
Infanmalima is correct. I agree to comply wit 11 all city and county
ordinances and state laws acing to building construction, and
PLUMBING
"FJ .,,z a
'
s
BOILER- COMP(3 H.P. or 100,000 B.T.U.) 6.00 s7;
BOILER -COMP IOvri 100,000 BTUI SEEFEE SCH.
MECHANICAL
hereby authorize repro n(aiives of city to enter open the
above-mentioned p Crty for ins Ion purposes.
(We) agree cove; Indo Ifycp hunnlcss the City of
MISC. - REFER TO ORD.
s
Cupertino ug' nst'liuhilit' ., j mnf„ costs and expenses which
Tiny in ap way uce ms it City in eonsalucIT of the
CONST. TAX
."
_ PERMIT ISSUANCE 10.00
grant ing pflhis pen'
`/ !J
MECH. CONT. LIC. NO.
MECH.
TOTAL
TOTAL
���.2U
nature ofAliplic' actor e e
INSPECTOR COPY