7171 t
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION ' PERMIT NUMBER
BUILDING
APPLICATION & PERMIT
ADDRESS
•' O .�loy -_. �..Y BUIL4DING,-ELECTRICAL-PLUMBING.-MECHANICAL 7171
NAMEHS OTV's' # iELEQTRIG� �'y � 6 HiFEE, PLAN CHECK VALIDATION
jl �rD PHONE
NnmERacroes / UTLETS-SWITCHES-RECEP 5.00/1.00 -�
eLOC.No. LIGHTING FIXTURES 5.00/1.00 <
porvr Eacro APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 5.00 /d DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
E NGINEEfi.
LIC.No, SIGNS TRANS.' � � 3.00
2TIRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
'
ZIP EMP.METER OR POLE INS. 15.00 J
ADDRESS MOTORS SEE FEE SCH.
aooREs
' SERVICE CHANGE 10.00
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Foo
LICENSED CONTRACTORS UECLARAfION 43 /
a 0 v 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
na (commencing with Section 70001 of Division 3 of the Business and
a ^ BLDG. ELECT. PLG. MECH.
r m i Professions Code,and mq license is in full Force end effect ❑ ❑ ❑
z o m - License Class G_/ Lic.Number�{Ts� -
Cr w r Date_f/� �i Contractor
..'BUILDING PERMIT'
¢ ¢ w a OWNER-BUILDER DECLARATION
ea MISC.- REFER TO ORD `-'b'INFORMATjUN,
X 3 a-H I hereby affirm ilio 1 son exempt 7 from the Cont motor's License - RMA
Law for the following reason. 7031.5,Business Professions PERMIT ISSUANCEVALUATION SIFT.
w E Code Any cityorcounty which requires a permit to construct,alter,
� �
¢ ¢QO improve.demolish,orrepair any structure,prior to its issuance,also ELEC.CONTR. + LIC.NO. ELEC. QO
0 ¢ requires the applicant for such permit to I ile u signed statement that i TOTAL /
u w ora a {" /C / PERMIT TO
he Is licensed pursuant to the provisions of the Contractor's License a
H z i Law(Chapter 9(commencing with Section 7000)of Division 3 ofthek, `L�7
- a Business and Professions Code)or that Ire is exempt therefrom and OTY. PLUMBING PERMIT' I '`-FEE>�'
¢ r o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
m by any applicant fora permit subjects the applicant to a civil penalty
ofoolmore than five hundred dollars(5500).): ALTER-DRAIN&'VENT-WATER (EA.) 4,00
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale(Sec:,7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CONO. 4.00
1 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 so.FT.PtooR aREA TOTALACREAGE
himself or through his own employees,provided that such improve-
( merits are not intended or offered(oriole.If,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM•OVER IEA.) 1.00 BUILDING USE
builderwill have the burden of proving that he did not build cr int- RES INP CON PB Omar
- prove lot purpose of Sale.). - INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property,am exclusively contracting with ❑ El ❑ 0 ❑
licensed contractors m construct the project(See. 7044,Business - LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code: fire 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
e'antrads for such projects with a contractorls)licensed pursuant to
the Contractors License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam ezempl under Sec. ,H.&P.C,for this WATER HEATER W/VENT '-' 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK E RS'COMPF NSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate ofconsent to selhiasum. ZONING - ENG.SITE N0.
or a cerlificate of Workers'Compensaion Insurance,or a certified
copy therepf($e�� 00,I.A.C.).
Policy No4Cmutu.y/�9'tf�P•�_(�,]rj��
0. ❑ Certifiedcopyisherehy�ru misled. FIRE$PRINK ENERGY T-24
Z Z yj(]� Certified rnp rc IIcJ rth h' inspection Division.
F O ,Cplrlicanl {!L/. :r f�,{Lfrt),4e S� MISC.- REFER TO ORD. Y❑ N❑ Y ❑ NEI
CC T CERTIFICATE OFdiXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.O.
W > COMPFNSATION INSURANCE PLG.CONTH. LIC,NO. PLG,
CL Z (This Section need not he completed if the permit is far one TOTAL Y 11 ND Y 0 No
hundred dollars($100)or less.)
V O I certity that in the performance of the work for which this per FEE SUMMARY tU} �.
LL F out Is Issued,I shallQTY"
not employ any person in any nnanner so as to s,,,MECHANICAL PERMir . FEE,-
L)
O become subject to the Workers'Compensation Laws of California. -
y Date Applicant - ALTER OR ADD TO MECH. 4.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
♦- z emption,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 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT ITO 10=C.F.M.) 3.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10000.EM.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance oT the work for which this permit is issued(Sec. MICROFILM
3097,CimC.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address' ELECTRIC
I Certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. 1 agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-DOW(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representativesof this city to enter upon time
above-mentioned property for inspection purposes. BOILER-COMP IOVBl 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 PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against said City in consequence of the
gra nttiing ma peon MECH.CONT. LIC.NO. - MECH.
L� TOTAL TOTAL'
Sig nature of Applicant/Contractor Y Dato�
OFFICECOPY