C 7175 APPLICANT TO, FILL.IN INFORMATION WITHIN-RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION RMI NUMBER
EHHHOING.. APPLICATION & PERMIT 717 5
ADDRESS. : BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
20300 $►��S cR.F.�lC SL.vD :. {µ q� 1$ d �T
N{{At��a,,E,�OWNERS '"* 4: T•(:n .'J 1' 1 1, +6 yam`.:&''• AN ECK VALIDATION
'rfwMFTffEUS OTY?' t +ELECTRIC PERMITN Fr. 'v ¢ t FEE".
I PHONE ^. x s
CONTRACTOR'S
,NAme n, UTLETS-SWITCHES-RECEP 5.00/1.00
CARS N. SweNson! Ca.T^�co 3 Q3 LIGHTING FIXTURES 5.00/1.00
CONTRACTORS APPLIANCES
PHONE
4.00 1 .
ADDRESS
PHONE t53�9b55 PANELS 5.00 DATE OF APPLICATION
'ARCHITECT SIGNS B.gD 'PLAN CHECK FEE P.C.NO.
OR
ENGINEER ('r/L.OI ,/
sec.NO. SIGNS TRANS. 3.00
ARCH.OR ENG. g-fig PERMIT VALIDATION
ADDRESS '. MCI
IT
• `• ZIP EM .METE R POLE INS. 15.00
s ADDRESS r'a MOT SEE FEE SCH.
ZQ-vd S12!6,g4.1 l�- 91_D✓ ISERVICE CHANGE 10.00
o¢i.
r�o o LICENSED,CONTRACTORS DECLARATION
.a v w I hereby al'firrrf that l am licensed under provisions of Chaplet 9 ISSUANCE DATE.
vHi s, ( ommenein with Section 7000)of Divisim,3 of Ibe Business and
U
`m g SLOG. E CT. PLG. MECH.
I-m io1'ese Ch Code,and my license is in full fore nd effuel. ❑ ❑ ❑
.z o x License Class Lic.Numbers03
O y-: Dutc Qmlmctar -
a m E BU `DING PERMIT
¢ ¢ a. OWNER-BUILDER DECLARATION r
A oa 0 - -_ FORMATION
w 3 LL r 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
F
u0 4 Law for the following return.(Sec 7031.5,Businessand Professions PERMIT ISSUANCE 6.00
VALUATION I $/FT.
� y Code:Anyckyorcoumy which requireca permit toccaustracl,alter,
¢ ¢¢0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTH. LIC.NO. ELEC.
Q LL requires the applicant for such permit to file a signed statement that TOTAL - gMIT TO
a w m he is licensed pursuant to the provisions of the Contractor's Liecnse
H z i
Law(Chapter 9(commencingwdh Section 7000)of Division 3 oftbe ;.1 s
a 'Business and professions(:ode)or that he Is exempt therefrom and QTY. rj(+q�* Ll 11M
PERMIT :�gt FEE
IF m the basis for the alleged exemption.Any violation ofSection 7031.5 ," ` *' "'S Ll 3''1'4' STORI 5 TYPE CONSTR.
ai- by any applicant for a permit subjects the applicant to a civil penany ALTER-DRAIN&•VENT-WATER (EA.) 4.00
of nos more than five Imndned dollars($500).1:
❑ 1,as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GR UP RES.UN 5
their sole compenvtion,will do the work,and the structure is not
tended 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 docs such work FIXTURES-PER TRAP 4.00 SO,FT.VLOUHAHEA TOTAL ACREAGE
himself or through his own employees,provided chat such improve-
^- mems are not intended or offered for sale.IL however,the building GAS-EA.SYSTEM-1INC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner GAS_EA.SYSTEM-OVER 4 IEA,) 1.00 BUILDING USE
builder will have the burden of proving Ilial he did not build or im- RES IND ON PB Drier
prove for purpose.of solo.). INDUSTRIALWASTE INTER. 20.00 ❑
❑ 1,as owner of the property,am exclusively contracting with
licensed contractors to crnstruct,the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSOR CEL NO.
and Professions Code:The Contractor's License Law docs not upply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
conifao is for such projects with.a contractods)licensed pursuant to
0m Contractor's License I.aw. SEWER-SANITARY-STORM EA.200ft/8.00 .TRACT N . PARCEL NO.
❑ I am exempt under Sec..,B.&P.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\ _ I hereby ate of thatWoo I have a certificate n of consent to self-insure,oked ZONING
or a hereby aff of Workers'Compensation Insurance,or t codified ENG.SITE N0.
co the,IT (Sec.3500,Lal, A
v, _ o. Compuny
O J Ce rt ified copy is hereby furnished. RIRESPRINK ENERGY T-24
Z Z C r[ified copy 's Cil ilh the city ' ion division.
• MISC.- REFER TO ORD
O Ajmbczm , y N[_ Y ❑ NE]
T -IiRTII°ICA'I'E07 EXIiMPTlO °ROMWORKfi PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C,
' LL > COMPIi NS At ION I NS RANCE PLG.CONTR. LIC.NO. PLG.'
C' o (Thus section need not be complete,] if the permit is for one TOTAL N�
Z hundred dollars IS IOD)or less) * =
U O I certify that m the performance of the work for which this per, r 'iti-rFEE�'SUMM°ARV tz"4-.
QTY,-., MECHANICAL PERMIT. ., FEE? �. r rY
U_ I- mit is issued, I shall not employ any person in any manner as Is Io z ,> -t n I <.
L)O become subject to the Workers'Compensation Laws of Cahforma. - L
0. Date - Applictne ALTER OR ADD TO MECH. 4.00 BUILDING
>_ W NOTICE TO APPLICAN'fi If,after making this Certiticale of Ex= `
Z_ ennption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions-id the Labor Code, you must forthwith comply with FEE
U such provisions or dais permii shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 3.00
CONST'RUC'TION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 - SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the penixmunce o1'life 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
Isnder's Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I ccrtity that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
x� information is correct:I agree to comply with all city and county. PLUMBING
ordinances and scale.laws relating to building construction, and BOILER-ODMP(3 H.P.Or 100,0008.T.U.) 4:00
Hereby authorise representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,00D BTU)SEE FEE SCH. MECHANICAL
(Wel agree to save; indemnify and keep harmless the 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
gmnlingof its 'L'• 1 y MECH.CONT. LIC.NO. MECH. ,e
"G.� ' TOTAL TOTAL•,
/1X/vn/ Signature of Applicene/C a tractor Dote --
. OFFICE COPY,