C9363 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES --USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON PERMIT NUMBER
BDILOING APPLICATION & PERMIT
ADDRESS
ey S c =K 8 ILDING - ELECTRICAL-PLUMBING-MECHANICAL 9363
OWNER S /f/ qN CHECK VALIDATION
\/ rvgME rL,J^ QTY. ELECTRIC PERMIT- FEE
CONTONE 1
NAAMpPACTOP3 ( UTLETS-SWITCHES-RECEP 10.00/1.00
LIC,NO. LIGHTING FIXTURES 10.0011.00
ADDRESS
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
O
PRONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT K,p�2P ASScC• PANELS (OVER 200 AMP)
20.00 PLAN CHECK FEE P.C.NO.
/ OR
J` ENGINEER
LIC.NC, - SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION
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XADDRESs Z¢ [p3 c,trDN,nn�; lr�.p SPECIAL CIRCUIT 5.00
IN V)G- J In, EMP.METER OR POLE INS. 20.00
ADDRESS p
AMOTORS SEE FEE SCH. � v
ADDRESS
SERVICE CHANGE 20.00 O'
O o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
it U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y a w (commencing with Section]000)Of Division 3 0l the Business and BLD ELECT. PLG. MECH.
H w z Professions Code,and my license is in full force and effect. ❑ ❑ O
o
0 m W License Class Lic.Number
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0
•Dale Contractor
a m E BUILDING PERMIT
0 EE u U OWNER-BUILDER DECLARA'HON •- INFORMATION
wLL H I hereby affrur that I am exempt from IIIc Contractor's License MISC.- REFER TO ORD VALUATION $/FT.
1 04 Law for the following reason.(Sec,7031.5.Idusinessand Professions PERMIT ISSUANCE 10.00
my Code:Any cityormanly which requiresupermittownstrucLalleq � �
G 0 int, ive,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC. 1
E o-LL, requires the applicant for such permit to file a signed statement That TOTAL 1t PERMIT TO
u w m • he is licensed puryuant to the provisions of the Contractor's License
H z a• `L'nw(Cha0ter9(commencing with Section 7000)of Division3of the
4 o
Bust"and'ProfessimiT'Codg)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
TIC H m The busts fdrahe alleged exempttoq.Any violation of Section 7031.5 STORIES I TYPE CONSTR.
A3: by any applicant for a permit mbjeclTthe applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars($500).):
'❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
sole compensation,will do the work.and the structure is not
intended or offered for side (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law docs not apply to an owner Of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 50.FT.FLOOR AREA TOTALACREAGE
• himself or Through his own employees,provided that such'in
prove-
ments 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 of completion,The owner- GAS-EA.SYSTEM OVER 4 (EA.) 200
builder will have the burden of proving that he did not build Tor im - . . BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND c0 PB Omer
❑ 1,as owner of the property.ant exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to mnntmet the ,.nice,(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSOR PARCEL NO.
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and Professions Code:'Phe Contractor's License Law does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCELING. 1
❑ lam exempt under Sec. .B.&P.C.for this WATER HEATER W/VENT 6.00 /
reason
Owne nate WgTER SYSTEM 5.00 ACC.DATE Acc.FILE No. I
x, WORK IIRS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(See.3800,Lub.C).
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z O Certified copy is fled with the city inspection division. MISC.- REFER TO ORD.
O Applicant _+.❑-✓'N❑ Y ❑. N❑
CC re, CERTIFIC\Tli OI'EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u2.
LU 1 COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG. y❑ N❑ Y ❑ N❑
OL Z (Phis section need not be completed if Ole permit is for one TOTAL
h undred dollars($100)or less)
U O I certify that in the ertomiance if Da work for which This Per, OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued, I shall not employ any person in any manner so as to \
O w become subject to the Workers'Compensation Laws of California. BUILDING Dare Applicant ALTER OR ADD TO MECH. 5.00
} W NOTICE TO APPLICANT: If,after making(his Certificate of fix-
? eruption,you should become subject to The Workers'Compensa(iun APPLIANCE 5.00 PLAN CHECK
provisions of The Labor Code, you mus( forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10)000C.F.M.) 4.00
CONSTRUCTIONTENDINGAGENCY AIR HANDLING UNIT(OVER 1Q000C.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is o 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.CL I HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address ` HEATING UNIT(OVER 100,000B.T.U.)9.50 ELECTRIC
I certify that l havesead'thisapplication and slate Thai 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'To building'eonstruction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize represenlutives'of This city to enter upon tli°
above-mentioned properly for inspection purposes BOILER-COMP Owen 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree t0 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
I may in any way�Cce agar st said Ciry in consequence of thei peMECH.CONT. LIC.NO. TOTAL /^'o40plContractor Dae �f ^ /
INSPECTOR COPY