C 7202 A!"VEICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BA POINT PEN ONLY
BU LD',BUI LDI NG PROJECT I DENTI FICATI PERMIT NUMBER
ING APPLICATION & PER
A�ba� 7202
��� ��` BUILDING-ELECTRICAL=.PLUMBING-MECHANICAL
OWNER'S s"Y1�.0- 2" .S - PLAN CHECy(Vf1;4,S_N
NAME GTV.-..,., �yy -,'•'
•�r_�-Y�^y -�� `,(' ''ELECTRIC.P�ERMIT FEE yp
ONE - ZCONTRACTORSNAME , , - OUTLETS-SWITCHES-RECEP 5.00/7.00V.� .
1_,- e.11� "��iic:No. LIGHTING FIXTURES 5.00/1.00
ADDDRRESSTDl'�r�� H/�( -7� 1 APPLIANCES-RESIDENTIAL 4,00
-y--v-� vi J�\ZPJION PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNSTRANS. 3.00
ARCH.OR
ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
h ZIP EMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
D SERVICE CHANGE 10.00 P ✓[[�� ryry(ppp/�8/�
woo LICIZNSI'-DCONTRACTOR$DECL ATION UN 2O 1JVS
I,• c v U I hereby afl'ion that I am licenser) under provisions of Chapter!) • ISSUANCE DATE
FA rt m (commencing with Section 7000)of Division 3 of the ILniness:mA _ BLDG. ELECT. PLG. ME H.
k 0 Professions Code,unduly license is in full force and effect.
o i=W License Class Lic.Number CI of CL pMrt non •E]
,A H Date Contmclor
a m f -J+ BUILDING,PERMIT '
E R w ¢ OWNER-BUILDER DECLARATION
A a A u INFORMATION
w ;LL N I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
' Hu.O J Lew for the lidlowing reason.ISec.70}LS,Business Professions PERMIT ISSUANCE .6.00 VALUATION S/FT.
4 Code:.Any city or county which re9uiresa permit loconstrucL.Iter, M�
¢ ¢¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. - LIC.NO: ELEC. ��/ w
o u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
A w m w he is licensed pursuant to the provisions of the Contractor's License - S��
HiQ
Law(Chapter 9(commencing with Section 7000)of Division 3 of the - - fes/ G
i Business and Professions Code)or that he is exempt therefrom and QTY: PLUMBING PERMIT "FEE GTLLit/
¢ I- $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a_ by any applicant for a pernhit subjects the applicant to a civil penalty
of not more than five hundred collars,($500).) ALTER-DRAIN&VENT-WATER (EA.) 4.00 -4-
Al,j,64�
❑ 1,as owner of the proncrty,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 - - OCC.GROUP RES.uNrtS
their sole compensation,will do the work,and the structure is not
intended or offered for Sulu (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CON D. 4.00 -..3
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 56 FT,FLOOR AREA TOTAL ACREAGE
himself re through his own employers.provided that such improve-
orim rovemennot rltendedwithinron year of completionhe,
owner-
GAS-EA.SVSTEM-11NC.40UTLETS 4.00 . 0/7
or improvement col is sob within one year of completion,the owner-
builder will have the burden of proving that he Aid not build or im- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
ploy 1,asfor owner
of theJ. INDUSTRIAL WASTE INTER. 20.00 y� I❑ ❑N ❑ D❑r
RI d as owner of the property,ants exclusively contracting with 10
licensed colons Cos m construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Frowner of Crop:The who
bildsContractor's License Law Joos not apply SS 7
to contracts
owner of property who builds to improves
enthereon.
pursuant
who LAWN SPRINKLERS-OVER 5(EA.) 1.00 3�d _IR•� _ Q�
the Cont for such projects with a mnlme(or(s)licensed pursuant to
' the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/5.00 TRACT NO. PARCEL NO.
❑ I exempt under Sec. ,BAP.C.for this WATER HEATER W/VENT 4.00
- reason
Owner Dale WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
)NKERS'COMPENSA'I'IO )ECLARATION WATER TREATING EQUIP, 4.00
I hereby atlirm that I have a certificate ofconsrnt to set&insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Certilicdcopyisbembyfslrnished. FIRESPRINK ENERGY.T-24
Z 2 ❑ Cerli(iml copy is filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y O NE] Y [:] No
N CERTIHCATT OF FXEMPFION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU COMPFNSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
�
0 (This section need not be completed if the Permit is for one TOTAL Y❑ NE) Yo. No
hundred dollars($100)or less.) ,
U O 1 certify that in the performance of the work for which(his per, G'TV " ,t M `+''•°yy '' ps+r;,+ N FEE SUMMARY
'.LL h- mit Is Issued,I shall not employ any person In any manner so as to x "w **y" v# ECHANICALxP,ERMIT i + BAdFEE n.
U become subject to the Workers'CGIRWIlletinn Laws of California. �D�
U y Date Applicant ALTER OR ADD TO MECH. 4 00 BUILDING
} In NO71CF'10 APPLICANT: If,after making this Certificate of Ex-
F 2 coalition.you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
promivisions of the Labor Code, you must forthwith comply with FEE'
U such provisions or this perl shall be deemed revoked. AIR HANDLING UNIT(TO 10,00DGF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 70p00C.RM.) 5.00 SEISMIC FEE 7sO
1 hereby athrnh that there is a construction lending agency for EXHAUST HOOD(WITH DUCT( 2.00
JJJ 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's Name H EATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that I haveread this application and state that the above VENTILATION FAN.(SINGLE) 9.00
C� information is rorecct.I agree In comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP 13 H.P.Of 100,000 B.T.U.) 4.00
hereby authorim representatives of this'city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE'SCH. MECHANICAL
a bovc-nhentioned property for inspection purposes.
C (We) agree to Save, Indemnify and keep harmless the City of - MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.SAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00 L_-
gumb flhls permit. MECH.CONT. LIC.NO. MECH.
TOTAL ,;.i TOTAL,`.. 07�
gn turco ant/Contractor
Day '4
OFFICE COPY