C 7133 APF ACANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI it
PROJECT I DENTI FICATION PERMIT NUMBER
LDINc APPLICATION & PERMIT 7133
DDR:55
JA:0 BUILDING-ELECTRICAL-PLUMBING-MECHANICAL ���///
OW R's �, ('•y9 PLAN CHECK LIGATION
NAME 7 �✓ OTY. ELECTRIC PERMIT FEE
I PHONE 7 VV
Co TRACTOR'S - UTLETS-SWITCHES-RECEP 5.00I1.00 714
NPME L
LIC.NO. LIGHTING FIXTURES 5.00/1.00
CONTRACTORS
ADDRESS -APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.No. SIGNS TRANS. 3.00
AIT C" OR ENG. - SPECIAL CIRCUIT $,QQ PERMIT VALIDATION
ADORLSs
ZIP TEMP. METER OR POLE INS. 15.00
APPLICANTS MOTORS - SEE FEE SCH.
ADDRESS
SERVICECHANGE 10.00 94L��
o o LICENSED CONTRACTORS DECLARATION
¢ I hereby aflinn that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w< w (commencing with Section 7000)of Division 3 of the Business and BL G. ELECT. PLG. MECH.
H<z Pro@ssiuns Code d my license is in full force a f t
z 0 m - License Gla s- Lic.Number C /y- ❑ ❑ ❑ .
o F w Dutc_��_ Contractor - ` �
a x BUILDING PERMIT
E ¢ w u OWNER-BUILDER DECLARATION INFORMATION
m3 u H 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
LLoa Law lirc the following reams.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE VALUATION $/FT.
L - Code:Any city or county whichrequimsapermittoconstfucLalter, 6.00
a ¢G 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. /
D LL requires the applicant for such permit to file a signed statement that TOTAL PERMIT T
A. w m he is licensed pursuant to the provisions of the Contractor's License
F z a
Low(Chapter 9(commencing with Section 7000)of Division 3 ofine /Zl1TEtZv <U/j %YdeI
4 o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
o3m byanyapplieanl lot a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(8500).):
CDI,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 Onactum is not
intended or uICTed ]or sale (Sea 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Con Tumor's License Law does not apply to an ownef of
` . properly who builds or Improves thereon,and who does such work F IXTUR ES-PER TRAP 4.00 SO.FT,FLOOR AREA TOTAL ACREAGE
f himself or through his own employees,provided that such improve-
mentsarenotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
bur lder will have the burden of proving that he did not build or im- RES IND CN vB Orher
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ 1,as owner of the properly,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESS RSP HCEL NO.
.,of Professions Code:'1'lie Cuntraofor'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
contracts for such projects with a comoaetor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200f1/8.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec. .BAP.C.for this WATER HEATER W/V ENT 4.00
reason.
Own - Date%,jf< WATER SYSTEM 4.00 ACC.DATE ACC-FILE NO.
WORK FRS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby ulllrm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
if a certificate of Workers'Compensation Insurance,or a eI,ni6ed
copy thereof(See.31400,Lab.C.).
Policy No, Company
Q (] CcrtilieA copy is hcreM1y lurnisheJ. FIRE SPRINK , ENERGY T-24
Z_ Z [D Certified copy is tiled with the city inspection division. MISC.- REFER TO ORD.
Y
Applicant E] NNC] Y ❑ N[_]F' � .
PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
C - CERI'IFICA'1'1:01'EXEMPTION FROM WORKERS'
W > C04I7NSA1'ION INSURANCE PLG.CONTR. LIC.No. PLG.
. O (Phis section n ed nit be completed if the permit is for ore TOTAL v❑ N❑ V ❑ N❑
D
DZ hu id red dol ku,IS 100)it less.)
U O 1 certily that in the performance of the work for which this per. DTV MECHANICAL PERMIT FEE FEE SUMMARY
LL l- mit is issued, I shall not employ any person in any manner so as to lL
00 bccono subject to the Worker Compensation Laws of California. BUILDING �9y
Date - Applicant ALTER OR ADD TO MECH. 4.00 U
} tan NOTICE '10 APPIACAN'I': If,after making this Certificate of Ex-
2 eruption,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 of this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000 C.F.M.) 3.00
CONSTRUcr1ON LENDING AGENCY AIR HANDLINGUNIT(OVER 10=1C.F.M.) 5.00 SEISMIC FEE
I hereby aflinn that there is a construction lending agency fur EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued ISCC. HEATING UNIT(TO 100000 B.T.U.) 4.00 MICROFILM
3097.Civ.C.). ,
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.P.50 ELECTRIC
Lender's Address
• I certify mat 1 have read this application and slate that the above VENTILATION FAN (SINGLE) 3.00
iolr
oation is correct. I agree to comply with all city and counly BOILER-COMPI3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and stale laws relating to building construction, and
hereby aumorue representatives of this city to enter upon the BOILER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above property for inspection purposes.
(we) agree to save, indenmity and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 ECONST.may in any way accrue against said City in consequence of thegranting of ll a Pemil. MECH.CONT. LIC.NO. MECHTOTAL
n.turC pl a n L't0 Dole
OFFICE COPY