7126 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE LL POINT PEN ONLY f
PERMIT NUMBER.
BUI LDI NG PROJECT IDENTI FI N . APPLICATION & PE' MIT '
aDILDiNn. - % 7126
/o�oR�Espy� • BUILDING_ELECTRICAL—PLUMBING—MECHANICAL �.
r/'•/• d p x, y� p y q�. PLAN CHECK VALIDATION
OWNER'5 '� Y 44i v 1
NAME OT�Y." ' �:;ELECTRICIPERMIn FEE
PHONE -
,; CONTRACTOR'S OUTLETS-SWITCHES-RECEP 5.00/1.00
NAME
1LIGHTING FIXTURES - 5.00/1.00
LI�C..^NO
CONTRACTORStGJ/ `r ,fQ PPLIANCES-RESIDENTIAL 4.00
A�E 11-
A H 0 N rra2r�;5L� PANELS 5.00 DATE OF APPLICATION
ARCHITECT •l SIGNS (j•DD PLAN CHECK FEE PO
.Q NO.
e.NGINI ER . , SIGNS TRANS. 3.00
'LIC NO. PERMIT VALIDATION
ARCH.oR ENG. SPECIALCIRCUIT 5.00
AOORESS _
' 'ziP EMP.METER OR POLE INS. 15.00-777
aPPLIDANr'S - - MOTORS SEE FEE SCH.
ADDRFss
SERV=", 2
10.00 .V
o¢ z I
'09 LICENSED CONTRACTORS DIiCLARATION
<v w 1 herchy uftirm that I am licensed under provisions of Chapter') ISSUANCE DATE
w< A (commencing with Section 7000)of Division 3 0l the Business andBLDG. ELEC PLG. MECH.
✓D i Professions Code,and my license is in full force and effect. � ❑
Z D m — License Class Lia Number ,
O z H Date Contractor
—
IT
OWNER-BUIL DISR oecLA'I(rcnoN 'kBU LDI G1PEHMI7
g ¢ w :,d' ^;;INFO,RMATION
MISCO ORD LL 1 hereby ul firm that I am exempt from lite Contractor's LicenseVALUATION S/FT.
oer Law for the following reason.(Sec.7031.5,Bminessand Profssions PERM6.00Code:Anycity orcounty whichrequiresaPermit toconstmcLxtler,¢Q 40, improve,demolish,of repair any structure,prior to its issuance,also' ELEC.CONT". EC. /JO requ lh-applicant fm such permit to file a tgned statement thatTAL (/F, PERMIT TO
w
a w m he is licensLJ pursuant to the provisions of the Contractor's 1.ianse _ . . h`ft Gv, `m '
Fzi Luw(Cllapler9(commencing wish Secti<m 7000)of Division Sol tlw •~k'. 's`says t"w .- ` - '-)"' '``v'v^Iv 'Ao v '9t by�FEEti.
a Business and Professions Code)or that tie Is exempt therefrom nJ QT1YP: �y "tia4,f,9P4LUMBINGQP�ERMIT .a�o-yawfa A x Z
'E i O Y'•q)e: k `i Y STORIES TYPE CONSTR.
¢ H the basis for the alleged exemption.Any.violaban ofSection7031.5 +, ul,s • a
5_: by by any applicant fora permit subjects the applicant macivilpenally ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(SSOOM:
❑ I,us owner of the property,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
Cede:'The Cnntrddor's License Law dnes,nnt apply to un owner of - -
'r properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,Proviiled that such improve- GAS-EA.SVSTEM•11NC.40UTLETS 4.00
tomenus 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.) 1.00 BUILDIN uSE
builder will have the burden of proving that he did not builder im-
prove l'or purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property,am exclusively contracting with -
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1•INC 5 V.B. 5.00 S&ESSORS PARCEL NO.
and Professions Code:The Contractor's I-icense Law does mit apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractods)licensed purstmnt to SEWER-SANITAR V-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
the COntraaor's License L.W.
❑ 1 am exempt under Sec. .B.&P.C.for Itis WATER HEATER W/VENT 4.00
or."m
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP.. 4.00
I hereby of@m that l have a certificate of consent to self-insure. - ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof l Sec 3800,Lab.C. .
Policy Nn. _Cern Pun in
Q' Tt' c PY 15 here furfisheL FIRESPRINK ENERGYT-20
Z Z ['ort 1'in oly s li cd w tic cit spection division. _ MISC.- • REFER TO ORD D. y N y N�
A p cant-
y PERMIT ISSUANCE . 6.00 FLOOO ZONE A.L.u.c.
cc — Cli f ;ICATF- ' .MPTION FROM WORKERS'
.w >_ COM'fi PION INSURANCE PLG.CONTE. LIC.NO. PLG. Y[] IN Y0, IN
CLOflhs section need not be completed if file permit Is for one _ TOTAL
� Z hundieddo1ls($100)or ICss1 - n`v' w ^mxv`A V �"br ''v '� 'FEE SUMMARY
U O 1 certify that In fhe'performance of the work for which thispus QTY MECHANICAL.P RMIIT
mit Is Issued,I shall not employ any person n any manner
Qw becomesuhjeet to the workers'Compensation Laws of Culilonua. BUILDINGr
Uatc� Applicant - ALTER OR ADD TO MECH. 4.00
} Daze. NOTICE'FO APPLICANT: If.after making this Certificate of Iix-
F ? emP!mm.you should become subject to the Workers Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the.Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10O0011F.M.), 3.00 -
CONSTRUCTIONLENDING pGIiNCV AIR HANDLING UNIT(OVER 10)=C.F.M.) 5.00 -SEISMIC FEE .
1 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.C.). HEATING UNIT(TO 100,000 B.T.U1 4.00 -
Lender's Name - HEATING UNIT(OVER100,000 B.T.1.1:17.50 ELECTRIC
Lenders Address-
I cerfily 0mt I have read this application and state that the above VENTILATION FAN (SINGLE). . 3.00
information is correct. 1 agree to comply with all'city and county PLUMBING
ordinances and state taws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH, MECHANICAL
above uncrowned property for inspection purposes. -
(We) agree to save, indemnify and keep harmless the City of MISC. REFER TO ORD. _
Cupertino against Imhi -s,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST TAX
�} mu n ny way ac u gains) said City in consequence of the
g ting f this perm t L 7 MECH.CONT. LIC.NO. MECH. h4 y-„ y
TOTAL `.
,TOTAL>)_71�.
Sig re of Ap ca ntmctor Date -
f _ _ OFFICE COPY _ - .