7071 a APPLICANT TO FILL IN INFORMATION WITHIN RED LINES _USE BALL POINT PEN,ONLY
rBU I LDI NG PROJECT I DENTI FICATION
PERMIT NUMBER
nooaess � APPLICATION & PERMIT 7071
-UQ BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
NAME
- y+ '',Y..!R ,y§{aby`✓;'�•, - : PLAN CHECK VALIDATION
IIELECTRIC,RERMIT� "O FELE
:J B TwG
eaNte Acrons UTLETS-SWITCHES-RECEP 5.00/1.00
LIC.NO, LIGHTING FIXTURES5.00/1.00 '
r-DDRs
ADDRESS
APPLIANCES-RESIDENTIAL 4.00
UREaa
PHONE PANELS, 5.00 DATE OF APPLICATION
ARCHITECT - SIGNS g,00 PLAN CHECK FEE P.C.NO.
ENGINEER
V[
LIC.No. Ca SIGNS TRANS. 3.00
AAn H OR DDRESS ENG. SPECIAL CIRCUIT' 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00 05 / r
APPucANra/�Jt- SN7 14.CL'jr - MOTORS SEE FEE SCH. .�(�J
ADDRESS
,
s-)Mn VS,t,2- CW-(- '%-SU T`7 ' SERVICE CHANGE 10.00
w o a LICENSED CONTRACTORS DECLARATION //�/�S'
<U w 1 hereby of firm that I am licensed under provisions of Chapter 9 ' ISSUANCE DATE
y a (commencing with Section 7000)of Division 3 of the Business and BLOC. I ELECT. PLG. MECH.
v w i Professions Code,and my license is in full force and effect. ❑ ❑ El ❑
oi L License Class Lie.Number -
F w H W Date Contractor
J All 1 BUILDING ERMI,T
¢ tc w
OWNR-BUILDER DECLARATION
" INFURMATtIU14 /.1.,
wka;LL Ii I hereby affirm that 1 am exempt from the Contractor's License MISC.- _ REFER TO
Law for the following reason. 7031.5,Business and Profos,unw, PERMIT IS
6.00 VALUATION S/FT.
fico E Code:Any city or county which requires a permit to construct,alter, -
ELEC.CONTR. LIC.NO.
¢ Se¢ o improve,demolish,or repair any structure,prior to its issuance,also - ELEC.
K O u requires the applicant for such permit to file a signed statement that TOTAL / , PERMIT TO
u w$ he is licensed pursuant to the provisions of the Contractor's License ,
Fzi Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe •+•+" ' ' ^��%L-/ /-" �zb•L7
¢ Business and Professions Code)or that he is exempt therefrom and OTY; 'PLUMBING PERMIT' FEE /
¢f0the basis for the alleged exemption.Any violation of8ectlon 7031.5 STORIES TYPE CONSTR.
n;� by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(5500)):
❑ I,as owner of the property,or my employees it,wages as BACK FLOW PROTECT.DEVICE 2.00 OCc.GROUP RES.urvtTS
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
property who builds or improves,thereon,and who does such work FIXTURES-PER TRAP 4.00 Set FT.FLOOR AREA 0 TOTAL ACREAGE
• himself or through his own employees,provided that such improve. -
meals are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM. 4(EA.) 1.00 BUILDING USE
huilder will have the burden of proving that he did not build or am: RES • IND CON PB Omar
pJor purpose of sale.). - INDUSTRIAL WASTE INTER. 20.00
I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
Xlied contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS 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 5(EA.)' 1.00
contracts 1'or such projects with u aIDlroctorls)licensed pursuant 10
the Contractor's license Law. SEWER-SANITARY-STORM EA.'200ft/6.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,RAP.C.for this -. WATER HEATER W/VENT 4.00 '
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00 -
I hereby affirm that I have a certificate of consent to sell-insure, - 20NING ENG.SITE NO.
(it a certificate of Workers'Compensation Insurance,or a cerlifed
copy thercuf(Scc.3800,Lab C). '
Policy No. Company
0 ❑ Certified copy is hereby furnished. FIRESPRINK ENERGY T-24
z Z' U Certified copy is filed with the city inspection division. MISC.- REFER TO ORD. y❑ N❑ Y❑. No
U Applicant -
Fy
CCCIiRTIFICPERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
- OMPE EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE PLG.CONTR.' LIC.NO. PLG.CL 'Y❑ N❑ YF], N❑
Z) U (This dollars
need not by completed if the permit is for one TOTAL
0 Z hundred dollars 131001 or less) t
U O I certify thm in the perfomlmme of the work for which[his pLr - ds' 4 EC '1 a y / r' FEE SUMMARY
aTV. ,� MECHANICAL'+,PERMIT K jqa 1 'FEE
LL H m11 is Issued,1 shall not employ any person in any manner so as to s .. ' +, 7 _ -
U become subject to the Workers'Compensation laws of California.
C. Date Applicant OR ADD TO MECH. 4•00 BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex-
Z eruption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Latior Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,0MGF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10pODGEM) 5.00 SEISMIC FEE
I hereby raffirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2-00
(he performance of the work for which this permit is,issued(Sec.
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lenders Address
I
I arlify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 3.00
information is correct.I agree to comply with all city and county PLUMBING
•, ordinances and state laws relating to building construction, and BOILER-COMP 13 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 1W,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
't (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments,coUs and expenses which PERMIT ISSUANCE , 3.00 CONST.TAX
may in any way ace a ago' [ i[ uh Forsailu ce of the
gPrhfln his per MECH.CONT. LIG NO. MECH. , )
C/' i A( PS TOTAL ,r. t�TOTJAtL r;
Signa um of Applicant ontractor le V +i
OFFICECOPY -