7044 APPLICANT,T'O FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECTI DENTI FICATION PERMIT NUMBER
DGILDING APPLICATION & PERMIT 7044
ADOREssCFO ID IDGE414G - ELECTRICAL-PLUMBING-MECHANICAL
OWrvER'S PLAN CHECK VALIDATION
NAME p ELECTRIC PERMIT FEE
'x., C Ro SV tE PHOrvE ,
CONTRACTORS TLETS-SWITCHES-RECEP 5.00/1.00
NC o� t uc.No. I 1 J1HTING FIXTURES 5.00/1.00
CONTRACTOR'StIf' „ ,�� C�(��P PPLIANCES-RESIDENTIAL 4.00
ADDRESS &0 ft- ` J
PHONE Al
PANELS 5.00 DATE OF APPLICATION
ARCHITECT 6.00
OR PLAN CHECK FEE P.C.N0,
SIGNS NS
LIG NO, SI G
ENGINEER TRANS. 3.00
ARCH.OR ENG. 5.00 PERMIT VALIDATION
ADDRESS SPE CI ALCIRCUIT
zlv EMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS ,
CHANGE SEE FEE SCH. 1` � J
ADDRESS `l.-1
SERVICE 10.00 r`/ p
_02 LICENSED CONTRACTORS DECLARATION /0 O S
G u U I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
us Q m (fnnlmenciny will Section 7000)of Divislan 3 of the Basin ll and RLOG. ELECT. PLG. MECH.
I-y Professions CodJAauu44 q�Iy license is in full fore ff ❑ ❑
o m Liccnsc Class S-...'2i a Liv.NumberXY
O - Dall:_��' -�� Contractor
F �H
a ¢w st OWNER-BUILDER DECLARATION BUILDING PERMIT
a F INFORMATION
E:
3 n 1 hereby affirm that I all exempt from the Contractor's License MISC.'- REFER TO ORD
g PERMIT ISSUANCE vALunrloN $/FT.
Fu Oa Lawfortheity ore reason.(Seeuires a,Eosin loand Professions 6.00
Code:Any city ar county which requires a permit Io conMnel,alter.
Hca 2 improve,demolish,or repair any structure,prior to its issuance,also ELED.CONTH. LIC.NO. ELEC.
o u requires lire applicant for,Such pcnnit to lilt a signed statement that TOTAL PERMIT TO
e w m he is licensed pursuant to the provisions of the Contractor's License vL v y i3 C
rzi
Law(Chapter 9(commencing with Section 7000)ofUivision 3 ofthe r
-a liminus and Profusions Code)or that he is exempt thsrsfram asul V. PLUMBING PERMIT FEE
ftp STORIES TYPE CONSTR.
Ir H$ the basis for the alleged exemption.Any violation of Section 7031.5
n ; _ by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
.four marc than five lumdod dollars($500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEV ICE 2.00 occ.GRDUP RES,UN IS
their sole compensation,will do the work,and the structure is not
intended lir offered for sale (Sec. 7044, Business and Professions PX DRAINS-FLOOR,ROOF,AREA,COND. 4.00 Iff
Code:The Contractor's Liccnsc Law due,not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PERT RAP 4.00 56 FT.FLOOR AREA TOTAL ACREAGE
• meats are of intended
own employees,
,Sle.If,ed however,tile
improve- GAS-EA.SYSTEM-I INC.40UTLETS 4.00
mems are not intended or offered y sale.If,however,Ilse building
or improvement is sob within one year ofdlio the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have tire lie die burden of proving that he did nott build m im- RES IND CON Pe Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ E-1 Cl
O 1,as owner of the properly,unI exclusively contracting with
licensed contractors to Construct lire project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:1'he C.mou,O is License Law docs not apply
to an ower of properly who builds m improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
n
vnnlracls Go Such projectswith a contractions)licensed pursuant to j�?s SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
tire Conteclor's License Law.
❑ l asnexempl under Sec. .B.&P.C.for this / WATER HEATER W/VENT 4.00
reason
Owner Dare WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPIiNSATION DECLARATION WATER TREATING EOUIP°' 4.00
1 trusty allinn that I have a evnificaty of consent to sckGimutc. ZONING ENG.SITE NO.
\ or a certificate of Workers'Compensation Insumuce.or a certified y
\T/
copy thereof(ser.3800,Lab.C.).GI ATIo.a 1 .'.I''I! `'
Policy Nn. Companyy�.�
U ❑ Cerlilie'ec Chereby famished. 1 FIRE SPRINK ENERGY T44
z' ❑ Cert)fief, WY Is riled w tit the city ,innsp coon division. MISC.- CIV OT REFER TO ORD. y ❑ N❑ v ❑ N❑
O Applicant�T-i�_ tf- /-Q--
� N CI?R1II:ICATIi 017 EXEMPTION FROM WORKERS' _ PERMIT ISSUANCE 6.00 FLOODZONE A.L.u.C.
U! >_ COMI'IiNSATION INSURANCE PLG.CONTR. LIC.IN 1r�f�r PLG.
CL O '- O G CVDNM-VJ I { Ip I TOTAL ,o�J y❑ N❑ Y❑ N❑
1'I'his' section lived not be completed if the penmt is for one
Z hundred dollars IS 100)or less.) FEE SUMMARY -
U O_ I certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE
0 F mil is is.Sucd,I shall not employ any Parson in any manner so as to
O W become subject m the Workers'Compensation Laws of California. BUILDING
Dale Applicant ALTER OR ADD TO MECH. 4.00
} y NOTIC17 '10 APPLICANT: If,after making this Certificate of 6x- 4.00 PLAN CHECK
Z cmptiun,you should become subject to le Workers'Compensation APPLIANCE
provisions of tie Labor Code, you must forthwith comply will FEE
U such provisions or this pcnnit shall be deemed revoked. AIR HANDLING UNIT(TO 1QW00F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IQO00C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00 MICROFILM
the perlbm
rance of lire work for which this permit is issued(Sec.
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UN IT(OVER 100,000 B.T.U.P.50 ELECTRIC
Lender's Address
Icertify that l have lead this application and state that the above VENTILATION FAN (SINGLE) 3.00• PLUMBING information is correct. 1 agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
onlirencu and state laws relating to building construction, and
hereby authorize representatives of this city to enter Inion the BOILER-COMP (Over 100,000 ETU)SEE FEE SCH. MECHANICAL
aboveancutioned property for inspection purposes.
(We) agree to Save, indemnify and keep harmless tine City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, Costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against said City in consequence of the
Lk' ofl isp mit. MECH.CONT. LIC.NO. MECH.
\/ roTAL TOTAL
rs Applicant/Contractor Datc
OFFICE COPY