C 7164 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
nooREss„t na/ 61-f0r 'C /M. /. &U/0 BUILDING - ELECTRICAL-PLUMBING-MECHANICA 7164
OWNEH's P,�*s Y j PLANCHECK VALIDATION
NAM'�E.�yy-ms� ;Pie- p QT,y:) m • E EC7'C�ERIN11'
�.G'/ C�,I/reP`HDNE Z57 1pg i. , "7`> VDi
NAAMERACTOR's OUTLETS-SWITCHES-RECEP _5.00/1.00 /
3
uc.No. LIGHTING FIXTURES 5.00/1.00 -)-7-
CONTRACTOR
2
CONTRACTORS
ADDRESS PPLIANCES-RE IDENTIAL 4,00
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHHTECT .+ SIGNS 8,00 PLAN CHECK FEE P.C.NO.
ENGINE IIYN/`F ' C Z
LIC.No. SIGNS TRANS. 3.00
ARCH,OR ENG, PERMIT VALIDATION
AODHESs pO Wl-h j � 5;c ?4A`D 7 SPECIAL CIRCUIT 5.00
7� r / [/ V i1PITy / EMP.METER OR POLE INS. 15.00
ADDREREssSS
AMOTORS SEE FEE SCH.
OO
SERVICE CHANGE 10.00 _
w o o LICENSED CONTRACTORS DECLARATION �
a, u I herehy aflimt char 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
stz a Icmnmenem with Section 70001 of Division 3 of the Business and
¢ R ELECT. I.G.PMECH.
r y i Professiuns Cade,and my license is in full force and effect. ❑ ❑ ❑
e 0 - License Class Lic.Number
Z
t o Date Contractor -
Y E PI.Ih,h'
OWNER-BUB-DER DECLARATION W,PZlBWI PING TIPIMM
'
w ;u r I hereby affirm that I am exempt from the Contractor'sVALUATION /FT.
r's License MISC.-= REFER TO ORD -'°Cn#'Ip�
u O J Law for the I'ullowing rcason.lSec.]031.5,Business and Professions PERMIT ISSUANCE I Q B
� - Code:Any city orcounty which requires a peon it toconstrud.alter,
22 ¢ � improve, or repair any structure,prior its issuance,alLso ELEC.CONTR. LIC.NO. ELEC. / /
O u requires the applicant for such permit to(Ile a signed statement that TOTAL 10 T•
x
as he is licensed pursuant to the provisions of the Contracmr's License
r i Q
Law(Chapter 9leommencing with Sermon 70001 of Division3of the ,.{;-•'' w t"c'�-'G;�i' ���Ajl"I"�7:7 /IV d
Business and Professions Code)or that he is exempt therefrom and QTY t-S- ;p.yPLUMBINO'PERMIT+•ti- EHE
M ro the basis for the alleged exemption.Any violation of Section 7031.5 r .f .7.7::i STORIESN R.
aim by any applicant for a permit subjects the applicant toacivil penally ALTER-DRAIN& VENT-WATER (EA.) 4.00
of not more than five hundred dollars(5500).):
❑ I,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 ISec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,GOND. 4.00 -
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 50.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees.provided that such improve- GAS-EA.SVSTEM-I 4.00
men's ren I intended or offered for sale.II',however.the building
r it overren1 is sold within one year of completion,the owner-
66 er will have the burden of proving that he did not build or on. GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
Inc, rparpare afvlle.). INDUSTRIAL WASTE INTER. 20.00 RES IND CON PB omar
] as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
1- ensed ,omracturs to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
nd Professions Codc:The Contractor's License Law does not apply
to an owner of property who builds Or improves thereon,and who LAWN SPRINKL ;�IRER 5(EA.) 1.00
contracts for such projects with a contractods)licensed pursuant to -
theCbntranor'sLicenseLaw. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
\ ❑ lamexemla.b rSec. ,B.&P.C.for this WATER HE WIVl NT_ 4.00
on
O - WATER SY TEM 4.00 ACC.DATE ACL.FILE NO.
4e d 1
WON IiR 'COM ENSA'TION IiCLARAT WATER TREMtJEftPeft119 4.00
1 hereby allirm that I have a certificate of consent to sel4insure' ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
ulpy thereof(Sec.38110,Lab.C.).
Policy No. Company
C) ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z ❑ Certified copy is filed with the city inspection division. MISC- REFER TO ORD.
O Applicant Y ❑ N❑ Y ❑ N❑
p: rn PERMIT ISSUANCE 8.00 FLOOOZONE A.L.U.C.
Lu ('ER'TI FICCOI PE I ATIO FINS FROM WORKERS'
Lu
a COMPot la, completed
INSURANCE PLG.CONTR. LIC.NO. TOTAL V � Y❑ N❑ Y❑ N❑
� Z mired
section S10 not he completed if the permit n for one
hundreJ dDILrs I f 1the pe form
U O I certify that h the to employ
an of the work for which this per- I'
LL F mil is issued.I shall not employ any person in any manner so as to
U become subject m the Workers'Compensation Wws of Califmon er
O W Date Applicant L ALTER OR ADD TO MECH. 4.00 BUILDING - D
} m NOTICE TO APPLICANT: If,after making this Certificate of Ex-
t 2 emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10p00C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p00C.F.M) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work I'or which this permit is issued(See. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
• Lender's Na
Lender me HEATING UNIT(OVER 100,000 B.T.U.)7.50
s Address ELECTRIC
[certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 3.00
inlbrmstion is correct. I agree to comply with all city and county PLUMBING (JI
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned 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 against said City in consequence of the PERMIT ISSUANCE 3.00
grantin lois permi . MECH.CONT. LIC.N0. MECH.
TOTAL
"6v�'f01"r"' /J�/ i�
S .TOTAL IBJ/
A licam ornractor to }-.q-
- � -e- e� OFFICE COPY