C9357 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
ADDRESS APPLICATION & PERMIT 9357
B ILUINs y
yr BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
AAMERa � ,'�� �� P N CHECK VALIDATION
• �OMEQTY. ELECTRIC PERMIT FEE
NR°CTORs OUTLETS-SWITCHES-RECEP 10.00/1.00
uc.ND. / LIGHTING FIXTURES 10.00/1.00
TRACTOR s I ADDRESS ///��, pPLIANCES-RESIDENTIAL 4.00
T ]e
S C IJ17OL ' a4E Ir 0 PANELS 10.00 DATE OF APPLICATION
AR H ECT {,.(',jam / `� pY1• * �^,', '^, PANELS (OVER 200 AMP) 2000 PLAN CHECK FEE P.C.NO.
EN('ilI•IEER I\J �IcI D I'�M �'`� �1"�
LIC NOSIGNS TRANS. 3.00
ARCH OR ENG. PER MIT VALIDATION
AODAE55 SPECIAL CIRCUIT 5.00
1 �J�' TEMP. METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH. /!��_._"•.'r•P.�`�
ADDRESS
QC SERVICE CHANGE 20.00 4 p�
woo LIC17NSED CONTRACTORS DECLARATION TEMP.POLE 30.00
< u w I hereby affirm Out I am licensed under provisions of Chapter ISSUANCE DATE
Nz (commencing with Section 7000)of Division 3 of the Business and
a n BL ELECT. PLG. MECH.
r N i professions Code,jV my license is in full force and effect
0 O m - License Class Li_ Lia NumberEL:y;{� ❑ ❑ ❑
Q Z. Date-Uate_ r 1 Contractor_
�q'a1
`a mBUILDING PERMIT
¢ a OWNER-BUILDER DECLA RA'fIOK INFORMATION
a o M s -
wu. m I hereby affirm that I am exempt from the Contractor's License MISC. REFER TO ORD
u 0 4 Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00 VALUATION 5/FT.
E - Code:Anycity orcounty which requires a permit to construct,alter,
rt ¢ Q Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
O ¢ requires the applicant for such permit to file a signed statinticatt that TOTAL I PERMIT 'O
he is licensed pursuant to the provision's of the Cootractoi s License
s H z i
Law(Chapter 9(commencingwith Section 7000)of Division 3 of the
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE s
¢ D the basis for the alleged exemption,An
¢ Hm ge pi y violation of Section7031.5 ORIES CONSTR.
ate _ by any applicant fora permit subjects the applicant tolicivilpenalty ALTER-DRAIN&VENT-WATER IEA.15.00
of not more than five Isundred doilars(S5000.):
❑ 1,as owner of the property,or try employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
sole compensation,will do the work,anti the structure is not
intended or offered fur sale(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 docs such work FIXTURES-PER TRAP 5.00 SO.PT.FLOOR AREA TOTALACREAGE
• hinsself or through his own employees,provided that such Improve-
mems arc 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-
builder
wner GAS EASYSTEM OVER 4 (EA) 200
builder will have the burden of proving that h - . - . .
e did not build or int- BUILDIN USE
prove fill purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 R S IND' PB Cur,
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑
licensed contractors Io construct the project(See.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSE550 RCEL NO.
and Professions Code:Tire 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 pu Ream to
the Contractor's License Law. SEWER-SAN ITARV-STORM EA.200ft/10.00 TRACT NO. PARCELNO.
❑ Ian.exemPlunder Sec ,B.&P.Ctix this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.DATE ACC,FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
1 hereby affirm that 1 have a certificate of consent to self-insure.
or a cerlificme of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy the r ,I(Se 3800,Lub.C.). '
Polley N sngiany
O ❑ Cc tific c hcrcb nishc
Z Z ❑ CCtl' C Y i f Willithe City i s division. FIRE SPRINK ENERGY T 24
Applicant MISC.- REFER TO ORD. Y❑ N❑ v ❑ N❑
c = CF R1'IFICATF:OF EXEMPTIONP I WOR 1RS' PERMIT ISSUANCE 10,00 FLOOD ZONE A.L.U.C.
LU 5; COMITNSATION INSI-FRANCE PLG.CONTR. LIC.NO. PLG.
( his section need not he completed if the penmil is for one TOTAL Y❑ N❑ Y ❑ N
Z 'P ❑
hundred&Alms IS 100)ar less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
U u Date Applicants- ALTER OR ADD TO MECH. 5.00 BUILDING O
} m NGT1CI7 TO APPLICAN'P'. If,after making this Certificate of E� Z cm Dmn,you Should hecome subject to lire Workcr,'Compensatinn APPLIANCE 5.00 PLAN CHECK'
provisions of the Labor Code, YOU nest forthwith comply with FEE
U such provisions or this permit shall be dccd nmrvv.kWL I AIR HANDLING UNIT(TO 10,000CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MOQEM.) 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,Cie.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address 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 to building construction, and BOILER-COUP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above-mm.tiancd properly for inspection purpose. BOILER-COMP(Over 100,000 BTUI SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless 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 Df 111emart. 1 MECH.CONT, LIC.NO. MECH.
// \ t �112TOTAL TOTAL 5
SLgnalure1 ppll ant/Contractor Date' ! T� '
f7/ l
INSPECTOR COPY
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