C 7248 APPLICANT TO FILL IN INF RMATION WITHIN RED LINES - USE BArL POINT PEN ONLY
• BUILDING PROJECT I DENTIFIWION PERMIT NUMBERBU LDING '. APPLICATION & MIT
f,ODRE55 ( / aJ G \8
BUILDING-ELECTRICAL-PLUMBING-MECHANICA
OWN H's - 'Xc _ ` •st !y, AN CHECK VALIDATION
"AYE 1 ' .1k�..y� k°YEIL CTR+LCrP•ERMIT F,E �'+*
faLV W V PHONE k,'•4�"w��M" .. 4,'ke:t�.. \w'*4``{•�.
NAMERAc7oRs OUTLETS-SWITCHES- 5.00/1.00
A V .ND,3°t6S'S3 LIGHTING FIXTURES 5.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00 .
4DDRE55
j!aPHONE S ',Q PANELS 5.00 DATE OF APPLICATION
AHC ECT - - PLAN CHECK FEE P.C.NO.
OR SIGNS 6.00
ENGINEER
' sec.NO. SIGNS TRANS. 3.00 -
ARCH.
ss ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRZIP ITEMP.METER OR POLE WS. 15.00
APPLICANT'S
- MOTORS
ADDRESS SEE FEE SCH.
SERVICE CHANGE 10.00 _
,02
0o LICENSED CONTRACTORS DECLARATION
Q U v I herby aflinn That I and licensed under provisions of Chapter 9 ,ISSUANCE DATE
rzii Iro(essiOns Codcl�andcllyn 700011onlfull foreivision 3 of lhfB mess and BLDG. ELECT. PLG. MECH.
Z, zo m o Licenx ass_ L Lie.Number ,CL�. ❑ ❑
o ❑ ❑
F y H j UatL ��j) Contractor A� '
E m s < - BUILDIN611PERMIT
¢ ¢� OWNER-BUILDER DECLARATION
M
w ;Re LL y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD _ INFORMATION
LL O 4 Law for the following reason.(Sec.7031,5,Business and ProfessionsVALUATION S/FT.
Icy W-! Code:Anycityorcounly which requires a permit to construct,alter, • PERMIT ISSUANCE 6.00
ELEC.CONTR. LIC.NO.
a ¢a o . improve,demolish,or repair any structure,prior to its issuance,also ELEC."
- ¢ requires the applicant for such permit to file a signed statement that TOTAL
A.
w m u. he.is licensed pursuant to the provisions of the Contractors License , PERMIT TO
r z i
Law(Chapter 9(commenemgwrlh Section 700()of Division 3 oflhe "^" FEE
4 o Business and Professions Code)or that lie is exempt therefrom an 1 Q..,,TVy',:yay' 4p+^ PLUMBING Py'ERMITn�.,.d,
¢ H ora the basis for the alleged exemption Any violation of Sechon 7031.5 ' ./J STORIES TYPE CONSTR.
n3 - by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(550().):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE. 2.00 DDD.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 docs not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP . ILJ 4,00 SD,FT.FLOOR AREA TOTAL ACREAGE
himself or throughhis own employees,provided that such improve-
mentsarenutintendedoroffered for sale.If,however,the building GAS-EA.SYSTEM-.l1NC.40UTLETS 4.00
or improvement is.sold within one year of completion,the owner- GAS-EA.SYSTEM-O E 4 E BUILDING USE;-O
builder will have the burden of proving that he did not build or im- RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 ❑r ❑ ❑
❑ 1,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1'INCt6t , Up $, ASSESSORS PARCEL NO.
and Professions Code:I tic Contractor's License Law does not 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 contractons)licensed pursuant to '
the Contractor's License Law. -( SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. B.AP.C.for this WATER HEATER W/VENT 4.00
reason
Owner Dale , WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby infirm that I Im c,a certificate ofcousent to self-insure,
ser a certificate of Workers'Compensation Insurance,or a certilied ZONING ENG.SITE NO.
copy thereof(Sec 3800,Lab.CJ.
policy No. Company -
0 0 Certif,d copy is hereby furnished FIRE SPRINK ENERGY T-24
Z_ z ❑ Certified copy,is filed with the city inspection division. MISC.- REFER TO ORD.
0 Applicant - Y ❑ No Y❑ NE]
LU -N_ CERTIFICATE EXEMPTION FROM WORKERS' PERMIT ISSUANCE• 6.00
FLOOD ZONE a.L.U.C.
COMPENSATION
INSURANCE PLG.CONTR. LIC.NO. PLG.
CL 0 ('This inion need not he completed if the permit is for one TOTAL Y NY❑ N❑
:) Z hundred dollars IS 100)or less.) '
L) 0 1 certify that to the.performance ol'the work for which this per.
''yy +- z- FEE SUMMARY
QTY','" *I;c MECHANICAL,'PERMITs., y
LL F nut Is issued,I shall not employ an I son in any m nner so as to " y, 4..
O L) hecome subject 1.the Workers; a sa lo�bp o IiftRltlu
y Date-App ALTER OR ADD TO MECH. '4.00 BUILDING
} W NOT I Cf- TO APPLICANT. If,after making this Cert f"iC51e of Lx
H ? cmplion,you should become subject.to the Workers'Compensation APPLIANCE 4.00 PLAN,CHECK
provisions of the Labor Code, you-must forthwithcomply with FEE
-U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTIONLENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
'I the performance of,the work for which this permit is Issued(Sec. MICROFILM
3097,Cie.C.). ., HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name H EATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00 jT
Information is correct.1 agree to comply with all city and county PLUMBING O
ordinances and state laws relating to building construction,and BOILER-COM P(3 H.P.or100,000B.T.U.) 4.00
hereby authorise roperty fatties ec this city to enter, uPun the BOILER-COMP IOvar 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purpoxs.
(We)"'agree to sa4e, indemnify and keep,harmless the City of MISC.- - ,REFER TO ORD. -
Cupertino against.liabilities,judgments, costs and expo-which PERMIT ISSUANCE, 3,00 - CONST.TAX
may In any lway accrue against said City in consequence of the
gmnfn tit.'Fermi MECH.CONT. LIC.NO. MECH. v
1--� �%CJ -li-bS TOTAL,
S(gmturc o(APPltcan Contractor Dale. °
OFFICE COPY --