C9137 :.`"APPLICANT'TO FILL IN INFORMATION WITHIN RED LINES - USE BALLPOINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON _ PERMIT NUMBER
BUILDING APPLICATION & PERMIT 9137
ADDRESS
10123 N. Wolfe Rd. BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PL CHECK VALIDATION
NAME - QTV. ELECTRIC PERMIT FEE
Banneton PHONE
CONTRACTORS OUTLETS-SWITCHES-PIECED 10.00/1.00
NAME
RAlgr LIGHTING FIXTURES 10.00/1.00
.B PPLIANCES-RESIDENTIAL 4.00
J AOOREBB JJ qqo
2430 Blac ow Rd. 1f.3NE� O-GO PANELS 10.00 DATE OF APPLICATION
T.-" TTremont, ca. PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDREss eNa SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. 20.00
ASMOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
wo o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
Q v I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE )
m C w (commencing with Section 7000)of Division 3 of the Business and - BLDG. ELECT. PLOT MECH.
w z Professions Code,an my Iia se is in full f rce'nd effe 1. ❑ ❑ ❑
Z o m - License Class Lie Numhe; VLEl
O 2 Ua1cConifactor -
a m E BUILDING PERMIT
¢ w ¢ OWNER-BUILDIiR DECLARAf1ON INFORMATION
o a ° MISC.- REFER TO ORD
X
; u- H I hereby alfirm first 1 um exempt from lire Contractor's License VALUATION
FUN ¢ Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
QQQD Improve,demolish,or repair any Structure,prior to its issuance.also ELEC.CONTE. LIC.NO. ELEC.
6 c M requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
n w ea he is licensed pursuant to the provisions of the Contractor's License
F z r
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe Relocate Fire B rkir
¢ Business and Professions Code)or that he is es rapt therefrom and QTV. PLUMBING PERMIT FEE p
(C it- o O v basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
i Rant by any applicant for a permit subjects the applicant to a civilpcnally ALTER-DRAIN&VENT-WATER (EA.) 5.00
ul not more than five hundred dollars(S500)):
❑ I,as owner of Alm property,or my employees with wages as BACK F LOW PROTECT.DEV ICE 4.00 OCC.GROUP RES.UNITS
(heir 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 v\
Code:The 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
• RmIr lace not
hde ownemployees,for sale.
if.ed that however.
improve- GAS-EA.SYSTEM-1 6.00
menus are not intended or offered for sale.If.however,the building
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden o'proving that he did not build or im- RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
); ❑ 1,as owner of the property.am exclusively contracting with
II licensed contractors to construct the project(Sec 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractors License Law does not apply
Is,in,owner of property who builds or improves them.....and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
1 contracts for such projects with a conlmctuns)licensed pursuant to SEWER-SANITARY-STORM EA200ft/1000
- . .
r'. the Contmelor's License Law. SEWERTRACT NO. PARCEL NO.
❑ I ani exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACG FILE NO.
,! 1
W'ORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
i I hereby affirm that I have a certificate of consent to self-insure.
or a certificate of Workers Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec 3800,Lab.C.).
O 1� 1i'o`yt'Rii" �o� l5Lp' v, grffi3 Erd-Rfa
FIRE SPRINK ENERGY T 24
Z Zi ❑ Certified copy is Bled with the city inspection divismu. MISC.- REFER TO ORD.O Applicant - Y ❑ NF] Y [:] N�
CC y
CC \ Cl:RTI PICA TIi OP IiXEh1I'I'ION FROM N'ORKI>RS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE. PLO.CONTE. LIC.NO. PLG. Y[] N� Y[] IN
i CL Z (This,seclion need not be completed if the permit is for one TOTAL
hundred dollars IS 100)or Ices.)
U O 1 Certify thal'in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- snit is issued, I shall not employ any person in any manner so as to
O w become subject to eWorkers'CompenialionLaws ofCalifornia. BUILDING
a
Date Applicant ALTER OR ADD TO MECH. 5.00
} m NOTICh TO APPLICANT': If,brio nw king this Workers'
iouipe sa lex-
(_ Z
ion,vtsionyou should become s you must the forth it Comply tion APPLIANCE 5.00 PLAN CHECK
provisions of the his Pr code, you muni forthwith col»ply with FEE
U vmh provisions or this permit shall be Aeemed revoked. AIR HANDLING UNIT(TO 10,000GF.M.) 4.00 650
CONSTRUCTION LENDINGAGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby aIfi n that<re 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.). 1 HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
:Ecndcr's Address HEATING UNIT(OVER 100,0008.T.U.)9.50 / ELECTRIC
` - I certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00 '
fnl'onnmion n correct. I agree to comply building
all city anti county PLUMBING
cmoriunces anti stale lawn relating to building conal ruction, and BOILER-OOMP(3 H.P.Or 100,0008.T.U.) 6.00
h
r"'1)
aulhoriu representatives of this'cily to enter upon the BOILER-COMP (Over 100,000 BTU(SEE FEE SCH. MECHANICAL
i. above-mentioned property for inspection purposes.
�We) agree to save, indemnify-and keep harmless lire City of MISC.- REFER TO ORD.
1 Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
{ may in any way accrue against said City in consequence of the
gra C`ing of this ermit. MECH.CONT. LIG NO. MECH.
TOTAL TOTAL 17.00
Signa of p ca r for Ii m
INSPECTOR COPY
„ I