9179 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILOING APPLICATION & PERMIT
aDDRE55 9179
'1 .L GMS EIC BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME
-� QTY. ELECTRIC PERMIT FEE
NAM[RAcroRs 1 UTLETS-SWITCHES-RECEP 10.00/1.00
LKt N"L LIGHTING FIXTURES 10.00/1.00
AV CONTRACTOR'S PPLIANCES-RESIDENTIAL 4.00
PDORE55
SF Z PANELS 16.06 DATE OF APPLICATION
' RRCNrtECt PANELS (OVER 200 AMP) 2000 PLAN CHECK FEE P.C.NO.
OR
N
ENGINEE
Lie,ND SIGNS TRANS. 3.00
ARCH.
ADDREORE SPECIAL CIRCUIT 5.00
G, PERMIT VALIDATION
EMP.METER OR POLE INS. 20.00
APPLICANT,St MOTORS SEE FEE SCH.
aOOREaS c
-(• �z SERVICE CHANGE ?0.00
o ¢ z `45 L .i
r o o LICENSED CONTRACTORS DECLARATION TEMP.POLE '30.00 �/T�Q-,(
a v U 1 hereby at Tiro that 1 am licensed under provisions of Chapter 9 'a7 ISSUANCE DATE
wz w (comnarcin•with Section 7000)of Division 3 of the Business and
¢ BLDG. ELECT. PLG. MECH.
H w zw S Professions Core,and my license is in full force and o feet.
oi u, Licmuc Class Lia Nun.her /
ti
are. m'.� Contractor
� - a � 1-aT 1tfAKi(N
a Y a BUILDING PERMIT
¢ m a OWNIi R-n U1LDIiR DGCLA RA PION
A o a v - INFORMATION
w ;a y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
u• oa Law fertile following reason.(See.7031.5.Business and Professions PERMIT ISSUANCE 10.00 VALUATION $/FT.
Code:Any city circularly which requires permit toconstruct,alteq `
Q or c o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. J f-00
ELEC� W
D u Y
requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO ,
F
mhe is licensed pursuant to the provisions of the Contractor's License
H z i
Law(Chapter 9(,commencing with Section 7000)of Division 3 ofthe MOL yJ/J -(/TG�✓Q�
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r c the basis for the alleged exemption.Any violation of Section 7031.5 - STORIES TYPE CONSTR.
n ; by any applicant for a permit subjects the applicant too civil penalty
of not more than five hundred dollars(5500).): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ 1,as owner of the property,or ruy employees with wages as BACK FLOW 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 ProfessionsDRAINS-FLOOR,ROOF,AR EA, D. 5.00
Code:The Contractor's License Law does not apply to an owner of
properly 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 employers, le.if,ed thus such improve-
merts are not intended or offered for sale. that such
he eeilding GAS-EA.SYSTEM-1 1INC.4OUTLETS 6.00
or improvement is sold within one year of completion the
- . . .
the owner- GAS EASYSTEM-OVER 4 (EA) 200
builder will have the burden of proving that he did not bd or im- BUILDING USE
prove for purpow ofsale.). INDUSTRIAL WASTE INTER. 30DO RES IND CON PB Other
❑ 1,as owner of the property,am exclusively contracting with Q ❑ ❑ ❑ ❑
licensed contractors m .....street the pmjecl(Sec. 7044, Resines LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
'and Profussions"Code"f he Con(carters License Law does riot apply
to un owner of property who builds or improves thereon,and who LAWN SPR INKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to SEWER-SANITARYV-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,H.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
W'ORKFRS'COM P17NSA IION 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'(Sec.3800,Lab.C.).
Policy No. Company
O 0 Certified Ally is hFIRE SPRINK ENERGY T.]<
erob F Ishe . ,rJ '
z Z ❑ Cutli(ie Opy islie i h 1) 'inspection division.
F p / Applicant MISC.- REFER TO ORD. V❑ NE] Y ❑ ME]
Cr y CIiRI'l PICA' iOP E. I'mp ON FROM WORKIiRS. PERMIT ISSUANCE 10.00 FLOOOZONE - --A:L-.u.C.-
. W CO.MPENSAI'IOI INSURANCE PLG.CONTR. LIC.NO. PLG v� NQ - v�
` CL Z (This section need not be completed if the permit is for one TOTAL N
hundred dollars(S 100)er Iess.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mit is issued, 1 slmll not employ any person in any manner so as to
O w become subject to the Workers'Compensation Laws of California.
D- Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
},m NOTICE TO APPLICAN"f. If,after making this Certificate of Ex-
F,? emptlon,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 he deemed revoked AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONS'I'RUCI'[ON LENDING AGENCY AIR HANDLING UNIT(OVER 10)000C.F.M.) 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 Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify Ilial l have read this application and state that Ote above VENTILATION FAN (SINGLE) 4.00
infornatiun is correct.I agree to comply with all city and courtly PLUMBING '
ordinances and stats: laws relating to building construcron, and BOILER-COMP(3 H.P.or100,000B.T.U.) 6.00
hereby au Umrrizc representatives of this city I.
enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indannify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,Jud ments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way ace a ag said ity in consequence of the
gmntin of tit pe LL MECH.CONT. LIC.NO. MECH.
6 4!V IgTOTAL TOTAL
n e o p int o r of Date
INSPECTOR COPY
I