C9138 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT 1 DENTI FICATION
PERMIT NUMBER
BUILDINGAPPLICATION & PERMIT 9138
ADDRESS
' BUILDING - ELECTRICAL-PLUMBING-MECHANICA
OWNER'SP AN CHECK VA LIDATION
NAME PHONE OTY. ELECTRIC PERMIT FEE
•
NOM¢RAc.ons UTLETS-SWITCHES-RECEP 10.00/1.00
XSWIMS TPTRE 'PROTECWTOR 429LIGHTING FIXTURES 10.00/1.00
ADNTRADTQf2430 BlacOW Rd. #3 PPLIANCES-RESIDENTIAL 4.00
Ca- 9453 HON _ PANELS 10.00 DATE OF APPLICATION
ORRCHITecr PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
uc.NO. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. 20.00 /
ADDRESS APPLICANTS MOTORS SEE FEE SCH. /\
( f /
SERVICECHANGE 20.00 vro
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
a mo U I hereby affirm that I am licensed undei provisions of Chapter 9 ISSUANCE DATE
"' (commencing with Seed....7000)of Division 3 of the Rosiness and
rl, a a BLDG. ELECT. PLG. MECH.
L. w i Pro Cusmonx CoQ r1L1 yy license is in full li rce and effect.
Z i+n -� License Class_I�-J�}_l.iC.Numb(r22�9 0 101 El El
H 51 Date Contractor ggfi,
a y F.� D if[IL.GG '•
a rc wa -17-85
A OWNCR-BUILDER DECLARATION BUILDING PERMIT
A o a u INFORMATION
X
; LL I- 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
L, Is E, Law for the following reason.(Sec.7031.5.Basin ass and Professions PERMIT ISSUANCE 10.00 VALUATION E/FT.
Code:Any city or county which requires a permit to construct,alteq
2 au a a improve,demolish,or repair any structure,prior to its issuance.also ELEC.CONTR. LIC.NO. ELEC.
I]a requires the applicant for such permit to file a signed statement That TOTAL PERMIT TO
E
he is licensed pursuant to the provisions of the Contractor's License !
H z a Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe IBZOCat
4 0 Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
+ w I_ the basis far the alleged exemption.Any violation of Section 7031.5 IE STR.
m
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.60
/ of not more than five hundred dollars(8500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
-plended or offered for sale(Sec 7044,Business and Professions DRAINS-FLOOR,ROOF,AR EA,CONE. 5.00
C3UeTh oContractor'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
himselfor through his own employees.provided that such improve-
mems are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 (EA.) 200 BUILDING
builder will have the burden of p - . - . . USE
roving that he did not build or im- RES IND CNG PB Omer
prove for purpose of sale.). . INDUSTRIAL WASTE INTER. 30.00
' ❑ I,as owner of the property,um exclusively contracting with El 0 0 El
licensed contractors to construct the project(Sec. 7044,Business ' LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
( and Professions Code:'I'he Contractor's License Law docs not apply 0A
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contractods)licensed pursuant to
the Contractor's License Law. j SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ l am exempt under Sea ,B.&P.C.fourth is ',WATER HEATER W/VENT 6.00
! reason �- -
Owner D:de WATER SYSTEM 5.00
ACC.DATE ACC,FILE NO.
WORK ERS'COMPENSA'TION DECLARATION Ir WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate demstot m self-insure. ZONING
or a certificate of Workers'Compensation Insurance.or a certified ENG.SITE NO.
copy thrKq[(�K,�Spljb.C.l.
Policy. `��'} bg �Iff.I�VnC.L vast-0t .,A Da
_ 0 ❑ Certified copy ishereby fum'Tel FIRE SPRINK ENERGY T 24
Z Z Certified copy is Bled witeh the city inspcctiun division.
0 plicant MISC.- REFER TO ORD. Y EJ N❑ I Y ❑ No
m 00
CC - \y CIiRTIPICATE OP EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10. FLOOD ZOrvE A.L.U.C.
LU > COMPENSATION'INSURANCE PLG.CONTR. LIC.NO. PLG.
4. 0 (This su'uclirin need nal be completed if' the permit is for one TOTAL v N Y(3 N
Z hundred d.IImms(S 100)or c"
U 0 1 certify that in the pertornwnce of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
EL-F- mit is issued,1 shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
a Date Applicant BUILDING
>_ W N'O"lIC17 10 APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. 5.00
Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provumus of the'Labor Code, you must forthwith comply with
L) such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M0 4.00 FEE 9.43
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending ugencv for EXHAUST HOOD(WITH DUCT) 5.00 -50
i
the 7cirforiv`..ree of the work for which this permit is issued ISec HEATING UNIT(TO 100,000 B.T.U.) 6.00 MICROFILM
Lender's Name HEATING UNIT(OVER 100,000 B.T.U. 9.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 r
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMPI3 H.P.or 100,0008.T.U.) 6.00
hereby authorve represenlatives.of this city' to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-Inantioned property for inspection purposes.
(WO 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 acerae against said City in consequence of the
granting of this permit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Sig hre +r p OI radar Date 24.43
INSPECTOR COPY
I