C09604 APPL••IQlANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDINGAPPLICATION & PERMIT
A09604
ADDRESS
x nIS FFA BUILDING-ELECTRICAL-PLUMBING-MECHANICA
OWNER'$ PLAN CHECK VALIDATION
NAME SE✓t/JS C/2t� 0,4 QTY- ELECTRIC PERMIT FEE
• Lam/" T YiSS C PHONE �f- I �'� ///��'Y �f' y
CONTRACTORS 1 -• V ro�Of
NamE R av HuTO UTLETS-SWITCHES-RECEP 10.00/1.00 4=
LIC.NO. LIGHTING FIXTURES 10.00/1.00 r)O
CONTRACTORS
ADDREAPPLIANCES-RESIDENTIAL 4.00
CO
PHONE PANELS 10,00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
' uc.NO. SIGNS TRANS. 3.00
AARCH OR DDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT r$
A - MOTORS SEE FEE SCH. -J
f
SERVICE CHANGE 20.00
0 LICENSED CONT RACTORS DECLARATION TEMP.POLE 30.00 /� 0
SE u w I hereby hffirm that 1 can licensed under pmvisiuns of Chapter 9 ISSUANCE DATE
¢ (commencing with Section 7000)of Division 3 of the Business andB G. ELECT. PIG. MECH.
F
yo Professions Code,and my'license is in full force and effect. _ - N
Z, Z m W License Class Lic.Number
Date Contractor
a Y f BUILDING PERMIT
IS ¢O IS viIS U OWNER-BUILDER DECLARATION INFORMATION
wm I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
3 u VALUATION E/FT.
t- u 0¢ Law for the following reason.(Sec.70315,Business and Professions PERMIT ISSUANCE 10.00 (N
Ew Code:Any cryor county which requires a permit to construct.alter,
p p' y prior to its issuance,also ELEC.CONTR. LIC.NO. OO O
¢ a ¢ o improve,Demolish,or repair any ELEC.
G u rey vires the applicant for such permit to file a signed statement that TOTAL 6 Q PERMIT TO
w $ he is licensed pursuaul to the provisions of Bm Contractor's License
F i
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
io Business hnd Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
IL 1- o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
nam by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(S500).):
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 4.00 OCc.GROUP RES.UNITS
their 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:'floc Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SO,FT.FLOOR AREA TOTAL ACREAGE
• 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-I INC.4 OUTLETS 6.00
or improvement is sold within one year of Completion,the owner- GAS-EASYSTEM OVER 4 (EA.) 200
builder will have the burden of proving trial . - . .
at he did not build or int- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IN o PB Omer
1711,as owner of the property,um exclusively contracting will] ❑ 11 11 1:1
licensed contractors to construct the project(Sec. 7044, Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 A5SE550R P HCEL NO,
and Professions Code:The 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 contractorts)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
,[he ContraClo's License Law. TRACT NO. PARCEL NO.
.❑ tarn rapt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner' 'd. Date WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO,
URKERB'C MPr1SATIONDI:CLARATI7 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(Sec.3800,Lai)C.).
Policy N.. Connpany
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z 2 ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
Q Applicant Y ❑ NEJ Y NE]
F: .00
LU
PERMIT ISSUANCE 10
- CER11131CATF-OF EXEMPTION FROM WORKERS' FLOOD 20NE A.L.U.C.
Lr>/ \CONIPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
2 (This section neeno
d t be Completed if the permit is for one TOTAL Y N V N�
hundred dollars(8100)or less.)
U O-' 1 certily that in the performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
L F mit is issued,I shall not employ any person in any manner so as to
U beconne subject to the Workers'Compensation Laws of California
ED +� Daze Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE TO APPLICANT': 11 after making this Certificate of Ex-
F. ? emption,you should become subject to the Workers'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 110=11F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.EM.) 6.00 SEISMIC FEE
1 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,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's m
ae
Lenders ... s
NHEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC 6 Q�
I certify that l have read this application and•stute that the above VENTILATION FAN (SINGLE) 4.001 At
�- information is Correct. 1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 1L„
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL U
above-mentioned property'for inspection purposes.
(We) agree m save, indemnify and keep harmless the City of MISC.- '"REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
mu t any why a cmc uguinsl said City in consequence of the PERMIT ISSUANCE 10.00
gr ng of this pet it. MECH.CONT, LIC.NO. MECH.
60 r TOTAL ;y TOTAL 3 `�
ifff A m
icant/ on otor Date
INSPECTOR COPY