C 7215 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJ C I TI I ATIO PERMIT NUMBER
n°ILDINc APPLICATION & PERMIT
A°DREsa _
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 7 2 15
OWNER' PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
Co
rR oRs UTLETS-SWITCHES-RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
r.OrvTHAcrons Z�' PPLIANCES-RESIDENTIAL 4.00
A7,t157;? 0y ' E PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
on
ENGINE
LIC.NO. SIGNS TRANS. 3.00
ARCH.oR ErvG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
AooREss
ZIP rFEMP.METER OR POLE INS. 15.00
AP.REss.ICANr
Aos MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00 /
w O O LICENSED CONTRACTORS DECLARATION
G v w I hereby affirm that I am licensed under prwislone 0f Cha PteT 9 ISSUANCE DATE
N G 'm IL nm mg with Stt a 7000)of DIV on 3 ul theBusinessand BL ELECT PLG. MECH.
I-w z 1 rofuswns Co a ed.Is In full
0 O m - L n Clnss a Lm NumHc'r ❑ ❑ ❑
O m r UrtL-J e2 Contractor (
acs L'rJ BUILDING,PERMIT •Hd
¢ ¢ w 4 OWNER BUILDER DECLARATION INFORNIATIONP.4•.,:rk
w 3 a r- I hereby allinn llmt I am exempt from the C'0nt,.ctur s Liccns" MISC.- REFER TO ORD
b PERMIT ISSUANCE VALUATION $/FT.
F I. o j law for the following•,comm.ISec.]031.5.Business and Prol'cssions 6.00 / �/�
Code:Any cityor county which requires a permit to construct,alter, ra( �-
¢ ¢¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
0¢ requires the applicant for such permit to file a signed statement that TOTAL U PERMIIT-O,
u w m u Ire is licensed pursuant to the provisions of the Contractor's License v
Law(Chapter 9(commencing with Section 7000)of Division 3 of the
4 Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ Fo the basis for t he alleged ex emption.A ny violas ion of Section 7031.5 LSTR_ES(rUp �rl-Y�ECONSTR.
a _ by any applicant for a permit subjects the applicant too,civil penalty ALTER-DRAIN& VENT-WATER (EA.) 4.00 1
of not more than live lumdred dollars(SSOO).1:
❑ 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 (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply t0 ml owner of
pruPerty whU hmllds or improves thereon,and who due,sut'I,work FIXTURES-PER TRAP 4.00 S°,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such"""ove-
ment,are not intended or offered for sale.IL however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvements sold within one year of conlplclion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that hedul not build noun.
prove for purpose or sale.). INDUSTRIAL WASTE INTER. 20.00 RES IND C PB Other
Cl I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ El
licensed contractor, to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESS 5 PARCEL NO.
and Professions Code:*1 he Contractor's Licenu Law dues not apply
to an owner of property who builds or improves Dlercon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such praj"cts with a contactors)licensed pursuant to
the Contmctor's cense Lea .B.&P.C.for Dtis aw. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lm ac,• eaund"r SWATER HEATER W/VENT 4.00
reuwn I
Owlle, Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK Ii RS•COMPF.NSATION DECLARATION WATER TREATING EQUIP. 4:00
1 ofift
at 1 have a ccrtifyy'ate ofcoment to seF
ZONING ENG.SITE NO.
or arkers'Compen lion Into once or a
Copy
PON O ❑ umishcd. FIRE SPRINK ENERGY T-24
2 YjSfjk�,d u y ' �yg'yion MISC.- REFER TO ORD. ❑ ❑ ❑ ❑
O APP /LS V N V N
= CERTIPICATF:OF EXEMPTION PROM WORKERS'
PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.O.
LU 1 COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
1 O ('Phis xetion need not be completed if lire permit is for o TOTAL V❑ N❑ V❑ N
2 Imndred doIUrs(S 100)or lessJ n�
U O 1xyroodtth"lluld
the performance of the work for which this per QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mitlnot employ any persem in any mann",soastoO w b"che Worker'C'ompensmion Laws is Caliritmix.DApplicant ALTER OR ADD TO MECH. 4.00 BUILDING
ICANT: If,after making this Certificate of ExF 2 anld become subject to the Worker's Compensation APPLIANCE -4.00 PLAN CHECK
Provisions of the Labor Code, you must forthwith comply with FEE
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEET
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the Perlimmance of the ork for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.1 4.00
Lenders Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Addrs
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
( • infonoution is correct. I agree to comply with all city and county BOILER-ODMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to caner upon the BOILER-COMP(Over 1OQ000BTU)SEE FEESCH. MECHANICAL
above mentioned properly for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgment costs and expenses which CONST.TAX
may m a accrue against sai ty in consequence of the PERMIT ISSUANCE 3.00
gami i MECH.CONT. LIC.NO. MECH.
Z� � TOTAL TOTAL" "
Si t o p (cant/Contractor Date
OFFICECOPY