9479 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING G�- _ APPLICATION & PERMIT
Aoo REss
AO C e,/7 BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 9479
a^ OWNER'S- vv _.._
NAME / PLAN CHECK VALIDATION
r� QTY. ELECTRIC PERMIT FEE 3 Q
( PRONE
NAME ACTOR TLETS-SWITCHES-RECEP 10.00/1.00 S6 7�
Pfz OM uc.No. LIGHTING FIXTURES 10.00/1.00 / /J/tfi
CONTRACTOR s PPLIANCES-RESIDENTIAL 4.00
OO j'l id
Ort y BONE ' PANELS 10.00 t GATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
�.
OR PANELS (OVER 200 AMPI 20.00
ENGINEER l S -F'
F I.C.INC. SIGNS TRANS, 3.00
ADDRESSENG. SPECIAL CIRCUIT yy 5.00 h PERMIT VALIDATION
'tp Zip EMP.METER OR POLE INS. 20.00 11.
ADDRESS Ts -I IY. MOTORS SEE FEE SCH. I
(1 SERVICE CHANGE 20.00
- 00 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 1�
1 hereby affirm that I am licensed under provisions of Chapter 9
z wISSUANCE DATE
e,
(commencing C with Section ]00a)i of Division 3 of the Business and
h2 Professions Code,an ny license is in lull fomean of et � - BL .ELECT. PLG.
im D License Class__Lie.Number_
w r DaleContractor- Cjz 1*..12 -
Q aC
a ¢ w a OWNER-BUILDER DECLARATION BUILDING R 1T
°a-u - MISC.- I REFER TO ORD ..� INFORMATION a
"w ac 1< I hereby el firm that I am exempt from the Business and
License t
ac Cow forthefollowingreason(Sea Tires a permit
to construct
Professions VALUATION $/FT.
� - •.� PERMIT ISSUANCE 10.00 44
w � Code:Any dryer county whiny reqstru tune,p for tots i suance,fter
also It
SE Q improve,demolish,or repair any slmchhre,prior to its issuance,alto ELEC.CONTR. UC.NO. ELEC.
requires the applicant forsuch permit to filo a signed statement that TOTAL
a w m y Ca sh. he u licensed pursuant to the provisions of the Contractor's License PERM TO
Law(Chapter 9(commenaingwith Section 70001of Division 3 of the
i o Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
X r o .the basis for the alleged exemption.Any violation of$ection 7031.5 STORIES TYCE CONSTR.
a ; °J by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars($500).) ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the since Uh re ei not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 -
code;The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PERTRAP 5.00 $o.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve- ,
ments are not intended or offered for sale,If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or am- GAS-EA.tSTEM-OVER 4 (EA.) 2.00 BUILDING SE
prove for purpose of sale J, RES IND N PB Ohher
D 1,as owner of the property,am exclusively contracting with
INDUSTRIAL WASTE INTER. 30.00
i licensed contractors to construct the project(See.7044,Business LAWN SPRINKLERS- 1 INC 5 00 ASSESSORS A CEL NO.
El El El E-1
and Professions Code.The Contractor's License Law docs not apply V.B.. .
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 contractorfs)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACTNO. PARCELNO.
❑ 1 um exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
ma on
Owner One WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm That I have a certificate ofconscut to sell insure. u
or a certificate of Work'ersy,Compensaton Insurance,or a certified ZONING ENG.SITE NO.
ropy thereof(Sec.3800,LabI.C:)_•'
Policy No. Company -
O ❑ Certified copy is hereby furnished.
z Z gG�Certiliedis file +8 nh the city inspection division FIRE SPRINK ENERGY T-24
FO Ap/+leant�.. .e MISC-- REFER TO ORD. YE:] N❑ Y ❑ N�
PERMITISSUANCE 10.00 l'
(L W CERTIIICA'I'E OF EXEMPTION FROM WORK HRS' �(/. FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
O (This section need not be completed if the permit is lot one TOTAL V N� Y ❑ IN
Z hundred dollar,IS 100). le".)
U El
O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
w. LL H mit is issued,1 shall not employ any person in any manner so as to
1 .p L) become subject to the Workers'Compensation Laws of California. i
If a Date-Applicant ALTER OR ADD TO MECH. 5.00 n BUILDING
.. )- N NOTICE '1'0 APPLICANT: If,after making this Certificate of Ex-
F. Z emption,you should become subject to the Worker 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 deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
1 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
YI 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 issuW(Sec. MICROFILM
3097,Civ.0 T • 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
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 6
information is correct. 1 agree to comply with all city and county PLUMBING
ordinances and.state laws relating to building conshior n, and BOILER-COM�I3 H.P.of 100,000 B.T.U.1 6.00
hereby authorize representatives of this city to color upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-remnlioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. x
I, Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX �:-...
r may,.h any way accrue against said City in consequence of the r st
granting OC this permit. p MECH.CONT. LIC.NO.dV MECH.
,••---- �^f .,..v TOTAL n TOTAL
, Shgnatur o App1 ntmctol' Dalc /1 �
INSPECTOR COPY ? t