C9136 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
ao ILDING - APPLICATION & PERMIT
X AOORE55 'MA 9136
C $'V BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
�.1 .5 R
r NAME PLAN CHECK VALIDATION
OTV. ELECTRIC PERMIT FEE
PHONE
CONTRACTORS
NA.E 1. D (� pv� NO. OUTLE -SWITCHES-RECEP 10.00/1.00 _
C.21' iL' 1'11 LIGHTING FIXTURES 10.00/1.00
CONTRACT rs PPLIANCES-RESIDENTIAL 4.00
ADDRESS
HONE _ PANELS 10.00 .DATE OF APPLICATION
ORRCHITECT W '.1 TVusf- PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO,
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH-OR ENG. PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00
ZIP TEMP. METER OR POLE INS. 20.00
Avvucnrvrs SEE FEE SCH.
AGOREss 10310 C1es�vJ Dr MOTORS y
SERVICE CHANGE 20.00
o S) LICENSE, ONT RACTORS DECLARATION TEMP.POLE 30.00
a u 1 hereby afNnn iha( I am licensed under provisions of Chapter 9 ISSUANCE DATE
H a w (commencing with Sectilon 7000)of Division 3 of the Rosiness and
y BLDG_ ELECT. PLG. MECH.
H w z Professions Code,and my license is in full force and effect. ❑ ❑ ❑ ❑
z o m - License Class Lit.Numbcr
O m H o Date Contractor
Y a4 BUILDING PERMIT
at OWNER-BUILDER DECLARATION
o a U MISC.- - REFER TO ORD INFORMATION
w ; u w I hereby affirm Otaltl am exempt from the Contractor's License
u0a Lawforthe f ollowing reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE W VALUATION S/FT.
� -
Code:Any city orcounly whichrequires"permit toconstrucl,alteq
20 improve,demolish,fir repair any stmctue,prior to its issuance,also ELEC.CONTR. w LIC.NO. ELEC. 7U�
O u requires the applicant for such permit to file a signed statement that TOTAL J - PERMIT TO
R
m w he is licensed pursuant to the provisions of the Contractor's License
FT Law(Chapter 9(commencingwith Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE Fu/`1 e �.
sio
K F o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
u ; c2 by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not prom 0mn Ove hundred dollars($500).):
❑ 1,as owner of the property,or my employees with wages as ggCK F LOW PROTECT. DEVICE 4.00 OCC.Group RES.UNITS
sole compensation,will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees.provided that such improve-
monis are not intended or offered for sale.IL however,the building GAS-EA-SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or an-
provefor purpose ofsale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ I,as owner of the property',am exclusively'contracting with 0 0
licensed contmgorsto construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Cod,The Contractor's License Law does not apply
10 an lowlier of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
Conirucl,for such projects with a cttmtmetoris)Ifcensed ptvsuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.for this, WATER HEATER W/VENT 6.00
reason
I RK. u.n'� WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
W RS'COMPIiNSA N ECLARATION .WATER TREATING EQUIP, 5.00
I herahy adirm that 1 hove a certificate of e0nsent to sdf-insure. ZONING
or a certificate of Workers Compensation Insurance,ora certified ENG.SITE NO.
Copy thereof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby famished. FIRE SPRINK ENERGY T24
Z Z ❑ Certified copy is filed with the city inspection division.
0 Applicant A MISC.- REFER TO ORD. y � N� v v ❑ NE]
~ rn PERMIT ISSUANCE 10.00
LU - f-IiRTIIlCCOTi 01:EXEMPTIONPROMW'ORKERS' FLOOD ZONE A.L.O.C.
W COAIPENSAI'ION INSURANCE PLG.CONTRf /' LIC.NO. PLG.
d Y� NE:] Y � N�
O (This section need loot be completed if the permit is for one � TOTAL
D Z hundred dollars(S 100)or less.) t�
U O 1 Certify that in the performance of Ihu work for which this per- FEE SUMMARY
LL I- mit is issued,I shall not emu0
ploy any persi"any I. nn
.aer sn as to QTY. MECHANICAL PERMIT FEE
U becmae subject to the Worker,'Compensation Laws of California.
0 i Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING O 0
} w NOTICE 'f0 APPLICANT': 11, it,,making this Certificate of
Ex-emption.you should become subject m the Workers'Compensation APPLIANCE\ 5.00 PLAN CHECK p
provisions of the Labor Code, you must forthwith comply with FEE p d_4U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO I0=C.F.M,) 4.00
,hr CONSI'RUC'ITON LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE
` I hereby affirm that there is a construction lending agency]or EXHAUST HOOD(WITH DUCT) 5.00 W
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lenders Address ELECTRIC
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
® infonnallnn is Correct. I agree to comply with all city and C.0 It PLUMBING
ordinances and state laws relating to building construction, and BOILER H.P.or 100,000 B.T.U.) 6.00
hereby auth0rine representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTUI SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costsolid expenses which PERMIT ISSUANCE 10.00 /Q V, CONST.TAX
may in any way accmo against said City in consequence of the
Iran ting of this permit - MECH.CONT. LIC.NO. METO
. TOTAL TOTAL -7 `O
y\ Signau o\Applican Conirac at `wAw
-+
INSPECTOR COPY