C 7030 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION t - IT NumBER
BUILDING APPLICATION.& PERMIT
ADDne
., k/ 1iDING-ELECTRICAL-PLUMBING-MECHANICAL 7 O 3 O
OWNER - ;' : ' , _ CHECK VALIDATION
NAME (IlkS '^`-ELECTRIC PERMIT i- s kFEE,11
'PHONE e - '
NAME A °H OUTLETS-SWITCHES-RECEP 5.00/100 _
N " LIGHTING FIXTURES - 5.00/1.00
r.DNTR c o PLIANCES-RESIDENTIAL 4.00
ADDn J
G E ' V tANELS 5.00 GATE OF APPLICATION
ARCHI EC PLAN CHECK FEE P.C.N0.
OR .. SIGNS 6.00
ENGINEER
LIC.NO. SIGNS TRANS: 3.00
ARCH.OR ENG. PERMIT VALIDATION
ADDRESS SPECIALCIRCUIT 5.00 .
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANT'S - MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00 �-
°w 0 0 LICLNS'UCONTRACTORS DECLARATION '
O L
w
Ie v U I hereby aff rit that 1 am licensed under n 3 1the of Chapter 9 ISSUANCE DATE
N G y (commencing with Section 7008)Of Division 3 of the in a BLDG. ELECT. PLG. MECH.
r w i Professions Code,and my license is in full force t.
Z 0 m- Lice B Class_ Lie.Number ❑ ❑ ❑ ❑
Is r w Dalc Contractor
< ,,2 , ,BUILDI NG4PERMIT"'
Be¢ W LDIiR UECLARA'TI
¢Be a u MISC.- REFER TO ORD "IN_F,ORMATION
'x ;u.m I hereby affirm(hal 1 am exempt from the Contractors License _ VALUATION
Fu0¢ Law for the following reason.(Sec.703 1.5,Business and Professions PERMIT ISSUANCE 6.00 '
Code:Any city or county which requires permit to construct,eller,
a2¢o improve,demolish,or repair any structure,prior to Ila issuance,also ELEC.CONTR. LIC.NO. - ELEC.
-DLL requires the applicant for such permit to file a signed statement that TOTAL p PERMIT TO
n w m he is licensed pursuant to the provisions of the Contractor's License
r i Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe 1 `" r 0-
i o Business and Professions Code)or[hal he is exempt therefrom and QTY.= 41*"!£PLUMBING PERMIT - - FEE;''
M F$ the basis for the alleged exemption.Any violation of Section 7031.5 > STORIES TYPE CONSTR.
a3 - by any applicant for a permit subjects the applicant loa civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars($500).):
Cl I,as 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-FLOGR,ROOF,AREA,GOND. 4.00
Code:The Contractor's License Law does not apply to an owner of -
properly who bulld5 or Improves thereon,and who does such work FIXTURES-PER TRAP 4.00 'SG.FT.FLO°R AREA .TOTAL ACREAGE
\� himself or through his own employees,provided that such improve. -EA:SVSTEM-111NC.40UTLETS 4,00
n ,
meals am not intended or offered foexcleAf,however,the building GAS
or improvemet is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4(EA.) 100 BUILDING USE
builder will have the burden of proving that h . . .
e did not build or im- RES IND CON PB Omar,
for purpose ofsale.). , INDUSTRIAL WASTE INTER. 20.00
❑ 1,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 ASSESSDRS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5IEA.) 1.00
contracts for such projects with a mnlrac(ol(s)licensed pursuant Io
the C°nlractor's License Law.. SEWERSANITARV-STORM EA.200ft/8.00 TRACT NO. (PARCEL NO.
Cl I am exempt under Sec. ,B.&P.C.for(his WATER HEATER W/VENT 4.00 -
reasnn
Owner 'Date - WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKS RS'COMPF.NSATION DECLARATION WATER TREATING EQUIP. 4.00 "
I hereby affirm that 1 have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or- 1'!cam of Work 'Co ensal' I ron C; '•r' i•
o c .3 �iQ
C an(
Q ❑ •by'f .isle E FIRESPRINK ENERGY T 24
Z Z ❑ Certi a cop i f ed ith Ili is n ° MISC. REFER TO ORD.
O Applicant V❑ N❑ Y❑ N❑
IY N Cli FICATEOFISXIiMPTION FROM WORKERS'~ PERMIT ISSUANCE - 6.00 FLOOOZONE A.L.U.C.
LU >_ - COMPENSATION INSURANCE PLG.CONTR. LOC.NO. PLG.
1 O (This 'lion need not he completed if Ilse permit is for one IOTA s v❑ N❑ Y❑ N❑
D Z hundred dollms(S 100)or less.)
U O 1 certify that in the performance of the work for which,this per, �TYa H4.'MECHANICAC PEflM1T$ y'' ' .3 +-FEE..^
LL F nut is issued.I shall not employ any person in any manner so as to i,
U become subject to the Workers'Compensation Laws of California.
0. Date Applicant - ALTER OR ADD TO MECH. 4.00 BUILDING
>_ DO NOTICE TO APPLICANT: IL after making this Certificate of Ex- -
? emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 .PLAN CHECK
forocrioni of the Labor Code,you must forthwith comply with FEE
U such provisions or this permit shalt be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 1000C.RM.) 5.00 SEISMIC FEE
I hereby affirm that Item is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
lire performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ C.f HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.P.50 ELECTRIC
Lender's Address
llcertify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply.with all city and county PLUMBING
01
ordinances and state laws relating to building construction, and
BOILER-COMPO H.P.or 100,0008.T.U.) 4.00 r
hereby authorize representatives,of this city to enter upon the BOILER-COMP IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(WB) agree to Save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabil'res,judgments, costs and expenses which CONST.TAX
may.in any way Be against said City in consequence of the PERMIT ISSUANCE 3.00
ling fif this per i. CONT. LIQ NO. MECH.
i 'm _� TOTAL TOTAL
atttla AdAll,bealbWootHictor )JR, I
OFFICE COPY