7045i
Z Z
F O
c j
L _
CL
UO
L 1
Ow
N
I- ?
.+
•
E
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING -MECHANICAL
PERMIT NUMBER
7046
BUILDING
ADORER
1 OWNER•
", „q hin>RCdcMsbVH "rE.
ELE+IC.s,R£R:gCIx{PC9tI ERMI -
d+ ' ✓
PLAN CHECK VALIDATION
NAME acroRs
UTLETS-SWITCHES -RECEP 5.00/1.00
Lc. NO,
LIGHTING FIXTURES 5.00/1.00
CADRESSONTRATOR5
APPLIANCES - RESIDENTIAL 4.00
PHONE
PANELS 5.00
DATE OF APPLICATION
ORCHITECT
ENGINEER
LICNO,
SIGNS 6.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH. OR ENG.
ADDRESS
ISPECIALCIRCUIT 5.00
PERMIT VALIDATION
ZIP
TEMP. METER OR POLE INS. 15.00
APPLICANT'S
ADDRESS
MOTORS SEE FEE SCH.
0
SERVICE CHANGE 10.00
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
ISSUANCE DATE
BLDG. ELECT. PLG. MECH.
License Class Lic. Number
❑ ❑ 1:1 ❑
Dale Contractor
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5, Business and Professionsp'ERMIT
Code. Any city or county which requires permit to construct, alar,
improve, demolish, or repair any structure, prior n its issuance, also
requires the dp unua for such permit to file a signed actor's i that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9(commencing with Section 7000)of Division 3oftile
Business and Professions Code) or that he is exempt it and
the basis for the alleged exemption. Any violation ofSection 7031.5
by any applicant for a permit subjects the applicant to2Civil penalty
of not more than five hundred dollars ($500).):
MISC. - REFER TO ORD
4 BUILQINGfP,ERMI
_F,ORMA`TI.O(Q§.+ ;
ISSUANCE 6'00
VALUATION $/FT.
,. \�
ELEC. CONTR. LIC. NO.
ELEC.W
TOTAL
PERMIT TO
PL a�..
STORIES TYPE CONSTR.
ajt AaJ+p ^*A,•t'R?7W.'M1e*'v d.�
QTYI ��..P{{LUMBFNTG,.,�`Pwy,ERM{T '.gggg E
}P`Li. y')n '1'Rt�'1?;�SIC{y,.,MEgy' rvJ -.
ALTER -DRAIN -WATER (EA.) 4.00
❑ 1, as owner the property, or my employees with wages as
their sole compensation, will the work, and the structure is not
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
Property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
ments are not intended or offered for sale. I f, however, the building
DRAINS -FLOOR, ROOF, AREA, COND. 4.00
FIXTURES - PER TRAP 4.00
GAS - EA. SYSTEM -1 INC.4 OUTLETS 4.00
SM FT. FLOOR AREA
TOTAL ACREAGE
Or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or im-
prove for purpose of sale.).RES
❑ 1, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM -OVER 4 (EA.) 1.00
BUILDING USE
IND CON PS Omar
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply
to an owner of property who builds or improves thereon, and who
Contracts for such projects with a contractors) licensed pursuant to
the Contractor's License Law.
❑ fames pt under Sec. ,B.&P.C. for this
reason
LAWN SPRINKLERS - 1 INC 5 V.8. 5.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
TRACT NO. PARCEL NO.
SEWER -SANITARY -STORM EA. 200ft/8.00
Wgl'ER HEATER W/VENT 4.00
Owner 'r Date
WATER SYSTEM 4.00
ACC. GATE
ACC. FILE NO.
WORKERS'COMPEN TIOI DECLARATION
WATER TREATING EQUIP. _ 4.00
1 hereby affirm that I have a certificate of consent to self -insure,
Or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE N0.
copy thereof (Sec. 3800, Lab.C.).
'
Policy No. Company
MISC.- REF_ER.TO.ORD.
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with thecity inspection division.
Applicant
FIRESPRINK
v N
❑ ❑
ENERGY T-24
v N
❑ ❑
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPE
(This section need not be RINSURANCEION
completed if the permit is for one
PERMIT ISSUANCE 6.00
FLOOD ZONE
V [] N
A.L.U.C.
Y [3 N
PLG. CONTR. LI C NO. TOTAL
hundred dollars C$ 100) or less.)
I certify that in the performance of lite work for which this per
mil Is issued, 1 shall not employ any person in any manner so as to
rr'r s' • E L +r. e ^vfi` -
er
QTY. MECHANICAC.P4ERMIT• _ FEE'
`yrs'. �a.
become subject to the Workers' Compensation Laws of California
S. ^ A+• w`v�'%`+1""• ' .`.
ALTER OR ADD TO MECH. 4.00
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
BUILDING
APPLIANCE 4.00
AIR HANDLING UNIT (TO 10=C.F.M.) 3.00
PLAN CHECK
FEE
'
emption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT (OVER 10=C.EM.) 5.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec.
3097, Civ.C.).
EXHAUST HOOD (WITH DUCT) 2.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address
H EATI NG UN IT (OVER 100,000 B.T.U.)7.50
ELECTRIC
VENTILATION FAN (SINGLE) 3.00
I certify that l have read this application and state that the above
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
PLUMBING
,p -
/
BOILER- COME (3 H.P. Or 100,000 B.T.U.) 4.00
BOILER -COMP IOver 100,000 BTU) SEE FEE SCH.
MECHANICAL
(We) agree to save, indemnify and keep harmless the City of
MISC. - REFER TO ORD.
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue against id Ct �. in consequence of the
grant' of AN pal
PERMIT ISSUANCE 3,00
CONST. TAX
MECH. CONT. LIC. NO. MECH.
TOTAL
r .,
OTA",L.
r�•, ;,
Sgnatur of AppiicantjCon Ladle
OFFICE COPY