C 7209 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - OSE BALL POINT PEN ONLY
BUILDING PROJECT I IDENTIFICATION MIT NUMBER
SUILDING APPLICATION & PERMIT (2,7 7209
I ADDRESS
VVV�� t) U� BUILDING ELECTRICAL-PLUMBING-MECHANICAL
T PLAN CHECK VALIDATION
•
NAME
_ MNI #+`✓,Yy,#Y}' Yy .A Ott il,�
5 z 5 QTgYEIECTRICPERMIT q, :f FEE. ' ?�
PHONE Y' J !/ _
CONTRACTORS UTLETS-SWITCHES-`F`IECEP 5.00/1.00
NAME
1�, LIC.No. OG LIGHTING FIXTURES 5.00/1.00
/
CONTRACTOR'SSv 'S PPLIANCES-RESIDENTIAL 4.00
/Vx1 ADDRESS �1//`` -
Z44)ls,c..4 HONE '-O PANELS , ( 5.00 DATE OF APPLICATION
ARCHITECT SIGNS ' 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER LIC.c.No. - SIGNS TRANS.
AnCH.OR ENG.' 5.00PERMIT VALIDATION
ADDRESS SPECIALCIRCUIT
z.P TEMP.METER OR POLE INS. 15.00
APPLICANT'S MOTORS .SEE FEE SCH.
ADDRESS /
SERVICE CHANGE 10.00 1 ��Scr �T
Tic o LICENSED CONTRACTORS DECLARATION j(
<it u hereby affirm that I am licensed under provisions of Chirac,9 - ISSUANCE DATE
m< w (Commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH,
F N z Professions Cq�g.y14s i Ilcy/se is in full f �e�y1,�jle{L�� El ❑ ❑ ❑
z Oen License ClassG.J6�7C.I L�/`/Lic.NumberM7�`'�
9.0
F w Da _Contmctor�/�
I- t• 7 CA '.�BUILDING1..t,PyERM1T
¢ ¢wa OWNER-BUILDER DECLARATION 'r-?�...I�NF`ORM Aifs10N
w - REFER TO ORD
a'.
;e w I hereby affirm that l of exempt from the Contractor's License MISC.- VALUATION S/FT.
Fu0J Law for the following reason.(Sec.7031.5,Business Professions PERMIT ISSUANCE 6.00G )
Code:Any city or county which requiresa permit toconstmctsalter, ��Q Q �
2 ¢c Q improve,demolish,or repair any structure,prior to its issuance,also ELECT CONTE. LIC.NO. ELEC. _
n a O requires the applicant for such permit to file a signed statement that TOTAL P EMIT TO`
x$ he is licensed pursuant to the provisions of the Contractor's License
i>
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe ..Y. -
E 4 o Business and Professions Code)or that he is exempt therefrom and OTYV PLUMBING PERMIT FEEi�
¢s-$ the basis for the alleged exemption Any violation of Section 7031.5 STORIES[ 1s T,yPE CONSTR.
by any applicant for a permit subjects the applicant loo civil Penalty ALTER-DRAIN -WATER (EA.) 4.00 l I1 L. -�I ftQ�
of not more than five hundred dollars(S5001.):
01,as owner of the properly,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 DOC.GROUP RES.UNITS
their sole Compenution,will Jo the work,and the structure¢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 to an owner of
• property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 ` SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments e not intended or offered for sale.If,however,the building GAS-EA.SVSTEM-1 4.
ar00
Of 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 that he did not build or owner
RES IND CON PB Olhn
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑ ❑
0 I,as owner of the property,am exclusively contracting with
licensed contmclors to construct the project(Sec. 7044,Business LAWN SPRINKLERS:11 INC 5 V.B. 5.00 AMESSORS PARCEL NO.
and-Professions Code:'Phe 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
contracts for such projects with a contructonan licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200E/6.00 TRACT NO, PARCEL NO.
❑ I am exempt under Sec..,R&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner ' Date WATER SYSTEM P, )4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
'I hereby affirm that I have a certificate of consent to self-insure, t'R 1 d. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy the reA 00,Lab C, r.� G
Policy No WCompany S..1 ar -
Q Q-Ce tfed Cop iabcral furnished. fL:r,l Af r'I- .,iii FIRESPRINK ENERGY T 24
ZZ ki e,etificd pis ed wi in •etion division. MISC- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
1"' � Applicant ' c
'PERMIT ISSUANCE 6.00 FLOOOZONE A.L.u.C.
CC > CF'R' 'ICATE OF EXEMPTION FROM WORKERS'
LU _ COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG. ,L�'�
O_ ❑ TOTAL/L! Y❑ N❑ Y❑ N(]
(The, section Decd not be completed if the permit is for one
0 Z hundred dollars($100)or less.)
L) 0 I certify that in the performance of the work for which this per- OTY. - MECHANICAL PERMIT FEE FEELSUMMARY,¢"j1
1- mil is issued,I shall not employ any person in any manner so as to
OW become Subject tothe WorkeriCompenutionLawsofCalifornia. BUILDING S�
Date Applicant I ALTER OR ADD TO MECH. 4.00
} W NOTICE TO APPLICANT: If,after making this Certificate of "a-
f- ? enlption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Cade, you most forthwith comply withFEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT ITO 10p00CF.M.P'3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p00CF.M.) 5.00 SEISMIC FEE t�
I hereby affirm'that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00 '
the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4,00 MICROFILM
3097,CY.C.).
Lender's Name HEATING UN IT(OV ER 100,000 B.T.U.P.50 ELECTRIC
Lender's Address
I certify that I have read this application and state that the above VENTILATION FAN(SINGLE) 3.00
in
is correct.1 agree to comply with all city and county PLUMBING Q �.
�0offences and state laws relating to building construction,and BOILER-CONIP(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 an way accme against id Clly in consequence of the PERMIT ISSUANCE 3.00
granting this permit. MECH.CONT. LIC.NO. MECH. < /
TOTAL TQ1TrAl . 4
S' ureof Ap ontmctor ace
OFFICE COPY