9332APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
INSPECTOR COPY
BUILDING PROJECT IDENTI FICATION'
APPLICATION & PERMIT
BUILDING -ELECTRICAL -PLUMBING -MECHANICAL
PERMIT NUMBER
9332
9UILOING
ADDRESS /f �sg STEUENs GQEE.�F BCYD
6 VL
i 1
J
OWNER'S
NAME ��/ �� ///na� rS-6o3o
\`TVD 2
PMO E
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
NAMFCONRACTORs
OUTLETS-SWITCHES-RECEP 10.00/1.00
LC.No.
LIGHTI NG F IXTURES 10.00/1.00
ACCTORs
ORESS
ADDRES
PPLIANCES-RESIDENTIAL 4.00
PANELS 10.00
PHONE
DATE OF APPLICATION
ARRCHITECT
O
ENGINEER
LIC. Na.
PANELS (OVER 200 AMP) 20,00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ADDRESS ENG'
SPECIAL CIRCUIT 5.00 In
PERMIT VALIDATION
EMP. METER OR POLE INS. 20.00
ZIP
n
APPLIANT'S
MOTORS SEE FEE SCH.ADDACSS
SERVICECHANGE 20.00
5
/ [
LICENSED CON TRACI ORS DECLARATIONTEMP.
POLE 30.00
u
1 hereby affirm that I am licensed under provisions of Chapter 9
(Commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
License ClassLie. Number
Date Contractor
ISSUANCE DATE
BLDG. ELECT. PLG. MECH.
❑ ❑ ❑
i
-
i
S
Lrequires
- OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for ntire ycitlloriounty whiche703LS,Busin essand Professions
LawCorfor Any cfolorwu nason.(Secy iresil 031., Bisit tones construct,
improve, demolish, or repair any structure, prior to its Issuance, also
the applicant for such permit to file a signed statement that
ha is licensed pursuant to the provisions of the Contractor's License
BUILDING PERMIT
INFORMATION
-
MISC. - REFER TO ORD
PERMIT ISSUANCE (ti
VALUATION
$/FT.
ELEC. CONTR. LIC. NO. ELEC.
TOTAL
PERMIT TO
athe
-'
Law (Chapter 9 (commencing with Section 7000) o' Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant to a civil penalty
of not mom than five hundred dollars (5500).):
OTV. PLUMBING PERMIT FEE
L6G .e,i
STORIES
TYPE CONSTR.
ALTER -DRAIN -WATER (EA.) 5.00
D I, as owner of the property, or my employees with wages as
their sole compensation, will do the 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 sad Professions
Code: The Contractor's License Law does not apply to an owner of
FIXTURES - PER TRAP 5.0050.
GAS - EA. SYSTEM -1 INC.4 OUTLETS 6.00
property who builds or improves thereon, and who docs such work
himself or through his own employees, provided that such improve
nlents am not intended or oticmd ho sale. If, howeveq the building
FL FLOOR AREA
TOTAL ACREAGE
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or iin.
GAS - EA. SYSTEM - OVER 4 (EA.) 2.00
BUILDING USE
Prove for purpose of sale.).
❑ I, as owner of the pY. am exclusively contracting wit),
RES IND . CON PB Otherwit
11 El El 1:1 11mpert
INDUSTRIAL WASTE INTER. 30.00
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: The Contractors License Law does not apply
to an owner of property who builds or improves thereon. and who
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
contracts for such projects with a conlmctoAs) licensed pursuant to
the Contractor's License Law.SEWER-SANITARY-STORM
EA. 200ft/10.00
TRACT NO.
PARCEL NO.
/
T
❑ Iamexemplam See ,Bs
.&P.C. for this.
ft'aSOn
HEATER W/VENT 6.00
Owner D a 19 =1L 4C
WATER SYSTEM 5.00
ACC.OATE
ACC. FILE NO.
WATER TREATING EQUIP. - 5.00
WORKERSTAM .� . 'PION DECLARATION
I hcrcby a Iran that I have a certificate ofcorewel to Mf -insure.
or a certificate of Workers' Compensation Insurance, or a eertil'ied
ZONING
ENG. SITE NO.
-
copy thereof (Sec. 3800, Lab.C.).
Policy No. Company
❑ Certified copy is hereby Rmhhcd. `
❑ Certified copy is fled with the city inspection division.
Applicant
FIRE SPRINK
YE] NE]
ENERGY 4l
V No
MISC- REFER TO ORD.
CERTIFICATEOFIAESIPIION FROM WORKERS'
PERMIT ISSUANCE 10.00
FLooD zorvE
A.L.u.C.
COMPENSATION INSURANCE?
!This section need not be completed if the pen.. it is for one
PLG. CONTR. LIC. No.
PLG.
TOTAL
hundred dollars(5100) or less
I certify that 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
OTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
bccovic nthject to the Workers Compensation Laws of California.
Date Applicant
ALTER OR ADD TO MECH. 5.00
NOTICE 1'O APPLICANT: If, after amking this Certificate of Eit-
APPLIANCE 5.00
AIR HANDLING UNIT (TO 10=CF.M.) 4.00
PLAN CHECK
FEE
unption, you should becomeobject to the Workers' Compensation
provisions of Bre Labor Code, you must forthwith Comply with
such provisions or this permit shall be deemed revoked.
AIRHANDLING UNITIOVER 10=C.F.M.) 6.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec.
3097, Civ.C.).
EXHAUST HOOD (WITH DUCT) 5.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address
HEATING UN IT 100,000 B.T.U.) 9.50
ELECTRIC
I C
VENTI LATION FAN(SING LE) 4.00
I certify that l have read this application and state that tire above
inl'onnatloa is correct I agree to comply with all city and county
ordinances and smle laws relating to building construction, and
PLUMBING
BOILER-COMP(3 H.P. or 100,000 B.T.U.) 6.00
herchy arolmn,c representatives of this city to enter upon the
above-mentioned property for inspection purposes.
801LER-COMP(Over 100,000 BTU) SEE FEE SCH,
MECHANICAL
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue against said City in consequence of the
MISC. - REFER TO ORD.
PERMIT ISSUANCE 10.00
CONST. TAX
gmnlin this permit.
MECH. CONT. LIC. NO.
MECH.
TOTAL
TOTAL
Snatureof App ic
igant/COntmeto Date
INSPECTOR COPY