5009 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT
B°"°'"` 5009
ADDRESS BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
Zo1�j �
OwHER'!T ,"� 4S - -�— PLAN CHECK VALIDATION
NAME 1 1 DTV. ELECTRIC PERMIT FEE
• PHONE�1—O 111
NAME""CTO"5 UTLETS-SWITCHES-RECEP 5.00/1.00
LIC,NO. LIGHTING FIXTURES 5.00/1.00
ronrRacroRs PPLIANCES-RESIDENTIAL 4.00
ADOREss
PHONE PANELS 5.00 DATE OF APPLICATION
ORCHRECTSIGNS g PLAN CHECK FEE .C.NO.
OR
ENGINEER
' uc.no. SIGNS TRANS. 3.00
noo"Ress ENG' SPECIAL CIRCUIT '6.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
• APPLICANT'S MOTORS SEE FEE SCH.
SS O
ADDREJ
SERVICE CHANGE 10.00
woo LICENSED CONTRACTORS DECLARATION •_y//
I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
f-w i Professions Coda,and my license is in full force and effect. ❑ ❑ ❑ El o m - License Class Lic.Number
o wx - Date Contractor
t
a - E t pg4y4pING PERMIT
Or C, w ¢ OWNER BUILDER DIiCLARA'NON' - RMATION
E: Or LL n I hereby effum that 1 am exempt Froin the Contractor's License MISC.- REFER TO ORD I�/ yq LUATION 3/FT.
ea ac Law for the following reason. 7031.5.Business Professions PERMIT ISSUANCE 6,00 1 ,v
Code:Any city or county which requiresa permit to construct,alter, (t A1..7Q O x1
a, Q 20 improve,demolish,or repair tray strict"rc,prior to its issuance,id, ELEC.CONTR. LIC.NO. -ELEC. Q lIVJJ"'1~•••EEf..+OY
- 0 u requires the applicant for such permit tu.file a signed statement that TOTAL PERMIT TO
F$ he is licensed pursuant to the provisions of the Contractor's Linnsc qty On„ /�/S7.QL.
> Liw'(Chapter 9(commencing with Section 7000)of Division 3 ofthe lVl101'1"Pl`f1tr1
-< Business and Professions Code)or the he is exempt therefrom a d DTV. PLUMBING PERMIT FEE
the basis for the alleged exception.Any violulion of Section 7031.S STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant oa civil'Rally ALTER-DRAIN -WATER (EA.) 4,00
of not more than five hundred dollars(S500).):
❑ h its owner of the property,or my employees with Paces as BACK FLOW PROTECT.DEVICE 2.00 GCC.GROUP RES.UNITS
who compensation,will do the work,and tire mn
e stcterc not
intended or offered for sale ISec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Cade:The Contractor's License Law does not applyto an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 S¢FT.FLOOR AREA TOTAL acREaGE
S himself re through his own offered
orsor s provided thus such improve.
InenbaR not hrougintended hisown(fend ees,provided that slhebuildipg GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion, tine owner. GAS EASYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or int- GAS .- RES IND CON PB Otnvr
pravfur purpose of sole.). INDUSTRIAL WASTE INTER. 20,00 ❑ ❑ ❑ ❑ ❑
I,as owner of the property,he exclusively contending with
Ki sed contraaod to a Cored the project(Sec..7044,Business LAWN SPRINKLERS-1 INC 5 V.B. $.QO ASSESSORS PARCEL NO.
and Professions Cede:l'hc Contractor's License Law does not apply
to antr owner of pr pr> cc who builds tr improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a cnntmdnrts)licenud pursomu m
Une Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 Tflacr No. PARCEL No.
❑ I am exempt mnder Sec. .B.&P.C.for this WATER HEATER W/VENT 4.00
reason
X
Date �TOw"er WATER SYSTEM 4.00 ACC.DATE ACC.FILE No.
WORKERS'COMPENSATION DECL-ARA NON WATER TREATING EQUIP. 4.00 -
1 herchy affirm that I have a certiticale of inn- aU to self-insure, TONING ENG.SITE NO.
or a certificate of Workeri Cumpnmtion Insurance,or u cerfi Red
copy thereof(See.3800,L ab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
ZZ ❑ Certified copy is Bled with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y ❑ N❑ y ❑ N❑
CC CER1'IFICA1 E OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
L.> COMPF,NSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y❑ N❑ Y ❑
1 N❑
0 (This section need not be completed If the permit is for one TOTAL
Z hundred dollars IS 100)or less)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
F mit is issued, I shall not employ any person in a y manner a as to
O hecomu subject to tine Workers'Compensation Laws of Cithl'orma �9 s�
y Dam ApplicantALTER OR ADD TO MECH. 4.00 BUILDING J
rn NOTICE TO APPLICANT: If,after making this Certificme of Ee-
F-. ?
empt ion,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Coda, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10=C.F.K(L) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby atfun tient there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(See. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3097,Civ.C.).
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify thin l have read thisappliection and slate that the.above VENTILATION PAN (SINGLE) 3.00
• information is correct. I agree ILER-1x3nw(3 H.P.or 100,0008.T.U.) 4.00 to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BO
hemby amhorue representatives of this city to enter Upon the BOILER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL
"hove-mentioned property for inspection'purposes.
(N'e) agree 10 save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in tiny way accrue against so City in consequence of the
rz tingoflhi permit. MECH.CONT. LIC.NO. MECH.
X- A+
QQQ1]-`�{r' TOTAL TOTAL
Signature o App(cam Contractor [late
OFFICE COPY