C9181 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FI CATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 9181
aooREss
' BUILDING -ELECTRICAL-PLUMBING-MECHANICAL,I
OWNER'S PLAN CHECK VALIDATION
l NAME C. ' MEtir �S"re a%
QTY. ELECTRIC PERMIT FEE
.-yCONTRACTOR 5 NAM - OUTLETS-SWITCHES-RECEP 10.00/1.00
- / e' 11C.N I ILIGHTING FIXTURES 10.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
PDDRE55 �`' _ .`
_JA
I / I 'W�S J PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
on PANELS (OVER 200 AMP) 20.00
ENGINEER
uc.No. SIGNS TRANS. 3.00
ARCH.
OR erG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
zI EMP.METER OR POLE INS- j1 20.00
APPLICANT S
ADDDRESSDRESSMOTORS SEE FEE SCH,
m, IAII
L ( 4/4
SERVICE CHANGE 20.00 p /
o o- LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a v u 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUA CE DATE
s,Q v'i (commencing with Section 7000)of Division 3 of the Business and BLD ELECT. PLG. 'MECH.
r- D z Professions Code, my license is in full farce and eC el.
z O m- License Class_Lic.Number I�
9 z w Date - 'a'I r� Contractor
a Zy-F-C--c-7- V,V-Av s/ - BUILDINGPERMIT
¢ ¢ w a OWNHR-BUILDEiR DECLARATION INFOR ATERM
ION
w ;? LL � I hereby affirm that I am exempt from the Contmtlois License MISC.- REFER TO ORD
uOj Law for the following reason, 7031.5.Bimmessand Professions pERMIT ISSUANCE 10.00 VALUATION $/FT.
� - Code:Any city or county which requiresa permit to construct.alter,
w p { y s "or to its issuance,also ELEC.CONTR. Lt C.NO. 0
¢ ¢ < o -
improve.demolish,or repair an structure,prior ELEC.
A wO ¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
m" he 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
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
(Imoo the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a ; m' by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).)'.
❑ I,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 structure is 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
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-
mentsarenot intended or offered for sale.If,however.the¢uilding GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is'sold within one year of completion,the owner- GAS EASYSTEM-OVER 4 IEA ) 200
builder will have(he burden of proving that he did not build - . . .
'or im- BUILDING USE
powvforpurposc of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Other
❑ I,as Darier of the property,am exclusively contracting with ElA ❑
licensed contractors to construct the project(Sec 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSOR ARCEL 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 foreuch projects with a contractorso licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200tt/10.00 TRACT NO, PARCEL NO.
❑ I am exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Dale 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 ofc.n,e.1 to w1pima re, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
X copy.lhereof IS .3800,Lab.C.).
Policy No Company
+� ❑ CeRifledc y'ishere y«forms FIRE SPRtNK ENERGY T$4
Z Z ❑ Certified py is,(�ed hi'Ih inspection division.
p� Applicro / MISC.- REFER TO ORD. YE] N� V � No
I- Ln PERMIT ISSUANCE 10.00
Cc - CERTIFICATF:OF CXGMPT{ N PROh1 WORF:C:RS' FLOOD ZONE A.L.0 C.
W 1 COMPENSATION' NSURAP Ii PLG.CONTE. LIC.NO. PLG. y� N� V� N�
CL Z (This section need not be comPlctcd if the permit is for one TOTAL
hundred dollars($100)or less.)
U 0 I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
EL H mit is issued,1 shall not employ'any person in any manner so as to
V become subject to the Workers'Com enzation Laws of California.
O.,wa Date Applicant e ALTER OR ADD TO MECH. 5.00 BUILDING S Q
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F" Z emption,you should become subject to the workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with -FEE
such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=11F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE � -
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 1
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00 1
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that 1 have read this application and slate that lire above VENTILATION FAN (SINGLE) 4.00
• information is correct.I agree to comply with all city and county PLUMBING
ordinances and slate laws relating to building construction. and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the 01 BOILER-COMP"(Over 100.000 STU)SEE FEE SCH, MECHANICAL
above-mentioned property for inspection purposes.
(we) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. ,
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way a$�� again 'id "ty in consequence of the
granting this pe diel. MECH.CONT. LIC.NO. MECH. Q
TOTAL
Si t e pli Dntra r ate
INSPECTOR COPY
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