7090 r1Uk h
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION - PERMIT NUMBER
APPLICATION & PERMIT
em LoiNG
Au E� OD !N Liti 6Pp-c BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 7090
/ OwrvE PLAN CHECK VALIDATION
-11 "AME Y- ELECTRIC PERMIT FEE
PHONE
r croRs (2 - /0 UTLETS-SWITCHES-RECEP 5.00/1.00
N L
1t.a, ` 3lGY� LIGHTING FIXTURES 500
0
DDRRRBS / .
AS o2APPLIANCES 40
P..N )1-7qt.
PANELS 5-00 DATE OF APPLICATION
RCHDECTSIGNS g.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
moo ESS ENG. .00 CIRCUIT 5.00 PERMIT VALIDATION
ZIP rFEMP.METER OR POLE INS. 15.00
APPLICANT'S
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
woo LICENSED CONTRACTORS DECLARATION Y 'S��
a U I hereby of lire Ibt I am licensed under provisions of Chapter 9 ISS/ ll ACE DATE
H Q i (v'umntencing with Section 7000)of Division 3 of the Business and u BLDG. ELECT. PLG. MECH.
F w i 1'rolessinns Cod nA iccnse is
f�LAIIIVrtON
zO contrac Lie.Num ❑ ❑J )' J BUILDING,PERMIT.OWNER-BUILDER DE
oA MISC.- REFERhTO ORDI INFORMATION'.
w ;u e. I hereby aflirm that I am exempt from the Contractor's License ^ - _ •• •' VALUATION $/FT. ,
F u,o a law for the following reason.(Sec 7031.5,Businessand Professions PERMIT ISSUANCE VI LY `r "'"'' 6.00
Code:Any city or county which m,uiresa permit toe mxtruCL allca
¢ rt Q 40 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEG.
- DLL requires the applicant for such permit to file aligned statement that TOTAL PERMIT TO
u Ia mhe is licensed pursuant to the provisions of the Contractor's License
Fri
i
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
{ BU LDI NG PROJECT IDENTIFICATION\ PERMIT NUMBER
BUILDING APPLICATION & PERMIT
AD E55
O � ,ia BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 7090
OWNER' w�'I PLAN CHECK VALIDATION
"AME OTY. ELECTRIC PERMIT FEE
`® PXONE
N NT CTORS G7 , �Q UTLETS-SWITCHES-RECEP 5.00/1.00
(Q tic.No. 3/�D LIGHTING FIXTURES 5.00/1.00
- rvTR R's •j Tom' 4 // APPLIANCES—RESIDENTIAL 4.00
F6RT
PNON 71 PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS B DD PLAN CHECK FEE P.C.NO.
On
ENOINEER, �. Lm.No. SIGNS TRANS. 3.00
ADDRESS BS ENG, - SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH. /
ADDRESS !!!
SERVICE CHANGE 10.00
wO o LICENSED CONTRACTORS DECLARATION
U I hereby affirm that I am licensed under provisions of Chupicr 9 ISSUANCE DATE
wG vAai (cosnmmmcing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLD. MECH.
F n z Pp fessions Cod it y 'cense is in full for nple�tgc
zo Licenu� Lia Numbe ✓ VV ❑ ❑ ❑ ❑
9 =w )mc _ Conimct
a m s BUILDING PERMIT
¢ tc w ( WNIiR BUILDER DE ARATION INFORMATION
wO' 1 here, affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
3 u y Y P VALUATION $/FT.
H u• oj Law for the following reason(Sec.7031.5,BusinessanJ Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to construct,alter,
t•Q ¢Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. V LIC.NO. ELEC.
D LL reiluires theapplicant for such permit t0 file a signed statcou nt ilial TOTAL PERMIT TO
.n w m he is licensed pursuant to the provisions of the Contractor's License
Hzi
Law(Chapier9(commencing with Seetion7000)ofDivision 3ofthe
a Business and Professions Code)or that he is exempt therefrom ant! OTY. PLUMBING PERMIT FEE
I=-o the basis'Cor the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicum fora permit subjects the applicant toueivil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not Future than five hundred dollars(S500),)
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compenulion,will do the work,and line 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 10 an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees.Provided that such improve- .
menu are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or ire RES IND CON Pa Omer
prove for purpose of ole.). 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 ASSESSORS PARCEL NO.
and Professions Code:'I'he 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 nor such
ceneLwith a contractorts)lieonud pursuant SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
the tractsaou is License Law.
CI Iam exe...pt older Sec,-,B.&RC.for this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKY.RS'COMPENSA1ION DECLARA'T'ION WATER TREATING EQUIP. 4.00
I hereby affirm Ilmt I have a certificate of consent to selfinsure. ZONING
or a certificate of Worker,'Comp' union Insurance,or a certified ENG.SITE NO.
copy thereof(See.3800,Lab.G.) /1
policy No. Company
O ❑ Certified copy is hereby fmirm,luld FIRE SPRINK ENERGY T-24
Z Z ❑ Certfi o y filed with the city inspection division. MIS - REFER TO ORD.
App lic CY❑ N❑ Y ❑ NE]
Icy i iIFICA'IIi OF I: mPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
W 7 CoMpENSAr,ION INSURANCE PLG.CONTE. LIC.NO. PLG.
CL O ''Phis a.�elion need nV riot be completed if the permit is for one TOTAL [:] "E] Y❑ N❑
Z) Z hundred dollars IS 100)or Tess.)
U O 1 certify that in the pcdurrrmnce of the work for which this per, GTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL f mit is issued,I Shull not employ any person in any manner so as to
U hecome subject to the Workers'Compensation Laws of Calitornia.
O LU Datc Applicant BUILDING
OL pp ALTER OR ADD TO MECH. 4.00
} rn No rl ICE TO APPI.ICAN'r: If,after making fills Certificate of L.
F_ Z enlPtlon,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 sort,provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000C.F.M.) 5.00 SEISMIC FEE
I hereby affino 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.U.) 4.00
Lender'sName HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's, atlress ELECTRIC
I certify that i have read this application and state that to above VENTILATION FAN (SINGLE) 3.00
. tonrulation is correct. I agree to comply with all city and county PLUMBING
ordinwmes and :are laws relating to building construction, and BOILER-COMP(3H.P.or 100,000B.T.U.) 4.00
hereby' authoriec representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-nmntioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, Costs and expenses which CONST.TAX
may in any way accrue gainst said City in coney cote of fine PERMIT ISSUANCE 3.00
gra' nl ihisp mit. MECH.CONT. LIC.NO. MECH.
� TOTAL TOTAL
S" attire Applicant/Conte r Yate
INSPECTOR COPY