7251 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALLPOINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING. APPLICATION & PERMIT
ADDRE B ��t yu
7251.+ BUILDING-ELECTRICAL-PLUM0ING-MECHANICAL
e
' O NEH'S � � � ,- PLAN CHECK VALIDATION
rvAMe
RIC PERMI
J. - OTY. ELECTT FEE
IPHONE
toMEHAcmns UTLETS-SWITCHES-RECEP 5.00/1.00
71. - ^1L Lic.rvo.-, Sa7.� LIGHTING FIXTURES 5.00/1.00 -
CONTRACTORS - PPLIANCES-RESIDENTIAL 4.00
ADOREss
f PHONE ''1rjZ PANELS S.00 DATE OF APPLICATION
ORRCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
NGINEEH
LIC.No. SIGNS TRANS. 3:00
ADDRESS E"G SPECIAL CIRCUIT 'S•OO PERMIT VALIDATION
ZIP EMP.METER OR POLE.INS. 15.00 -
APPUGANrh
ADDREss MOTORS - - SEE FEE SCH.
SERVICE CHANGE 10.00
o o LICENSED CONTRACTORS DECLARATION
a v I hereby affirm that I am licensed under Prnvisimis of Chapter 9 ISSUANCE GATE
H Q m (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT, PLG. MECH.
F n z 1'rafessiuns COd�,and Icy cense is in full force, d f•'t • ❑ ❑ ❑
oz m o I-iccose Clasx_[,.%>(�Lic.Numhc S
m F w Date Comraclor '
- -d
rc w a - OWNER-BUILDER DECLARATION BUILDING PERMIT
E:
;LL w I hereby affirm that I am exempt from the Contractors License
MISC.- REFER TO ORD INFORMATION
F._ o J Law for the following reason.(Sec.7031.5,Businessund Professions PERMIT ISSUANCE VALUATION $/FT.
Code:Any city or courtly which requires a permit m ccu slrucL sEer, 6.00
¢ ¢ ¢0 improve,demolish,or repair any structure,prior n it,issuance,also ELEC.CONTR. LIC.NO. ELEC.
E O LL requires the applicant for such permit IO IIIe it 9lgned statement that TOTAL
6•W m lie Is licensed pursuant to the provisions of the Contractor's License
PERMIT TO
Law(Chapter 9(emomenaingwith Section 7000)ofDmision 3 ofih a;.; 'n[�u4tk,y��l..a;: PLg 6y
4 o Business and Professions Code)or that he is exempt therefrom and OTY: I PLUME 3 PERMIT FEE r
¢ 1- m the basis for the alleged exemption.Any violation of5ectmn 7031.5
k �t•` 'a'R STORIES TYPE CONSTR.
a3 _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not omrc than five hundred dollars($500).): -
❑ I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 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. 4.00
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 !1.00 Sp.FT.FLOOR AREA TOTAL ACREAGE.
himselfre through his own employees,W.If,ho ever,thiniprove-
or nts improve m it is
w thinoffered
onefor
year
If,however,the building GAS-EA.SYSTEM-1 INC.4OUTLETS 4.00
or improvement is held within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
prove for purpose of suleJ. - RES IND CON PB Othe,
❑ I,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. - 20.00
IicenseA contractors to construct the project(Sec. 7044,BusinessLAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:Tile Contractor's License Law does not apply -
ID an owner of property who,builds or improves lhererm.and who LAWN SPRINKLERS-OVER 5(EA.) 1,00
contracts for such project,with a contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO, PARCEL NO.
❑ Lai exempt under Sec. ,B.�P.C.for this
reasonWATER HEATER W/VEMAJ[) 4.00
'
Owner Dun WATER SYSTEM _ 4.00 ACC.DATE ACC.FILE NO,
WORK F.RS'COMPENSA'fION DECLARATION WATER TREATIN I QUIPS IJ ly J 4.00
I hereby affirm that 1 have a certificate ofennsenl to self-insure,
or a certificate of Workers'Compensation Insurance,ar a certifiedZONING ENG.SITE NO.
copy thereof(Sea 3800,Lab C.). - / `U B
Policy No. Company
0. . ❑ Cartilied copy hereby furnished. - FIRE SPRWK ENERGY T-Z4
Z Z ❑ Certified.copy is filed with the city inspection division.
FO Apphc:mt MISC.- - REFER TO ORD. Y0 N Y [:] N[]
ccN CIiRTIPICA'I'Ii OPIi%EMPI'ION FROM WORKERS' PERMIT ISSUANCE
6.00 FLOODZONE A.L,U.C.
UJ > COMPENSATION INSURANCE PLG,CONTR. LIC.N0. pLG. gt
Q. O (This section need not he completed if the permit is for one TOTAL O ^ Y❑ NE] V C] NC]
Z hundred dollars(5100)or b'%) - n v
U O I certify that in the performance of the work for which this per QTY; %� i4y1ECHANICAL'-PERM T `�"`xl k -s'' 4, <*Yq,FEE SUMMARY
.
LL
H• nut rs Issued,I shall not enmloy any person in any manner so as to ,+! $ k .,'x`}��i A,FEE(K r�s74,+.ea.a,L,
V become subject to Ole Workcn'Com n� w GCa fD i+..,,
D a Date Applicant a " ALTER OR ADD TO MECH 4.00 BUILDING '
> V) NOTICE TO APPLICANT: If,after making this C&Iificale of Ex-
F Z' cmplion,you should become subject to the Workers'C.mnpensatmm APPLIANCE 4.00 PLAN CHECK
provisions of die Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,ODOGF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10ACC.RM.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for - EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit Is Issued(Sec. MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 4.00
nder's Name
LeHEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address - ELECTRIC
I certifyahut I have read this application and slate that the above VENTILATION FAN (SINGLE) 3.00
information n correct 1 agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances hand state taws relating t. building mnster uion, and
hereby authorize representatives ins of This city to enter upon the BOILER-COMP(Over 101),000 BTU)SEE FEE'SCH. MECHANICAL
above-mentionLvl 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 ' 3.00 CONST.TAX
may in 'ti^ny way accrue against said City in consequence of the
g�
Oft fSpermLL f{��r"'- MECH.CONT. LIC.NO. MECH. - w „T.„.' y
/! /I''.l d TOTAL v azpa'-,TOTAL ,
5 gn( awl rem pplmant Contractor Dale
OFFICE COPY - -