7079 (2) I
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
,. BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDIRG /I APPLICATION & PERMIT - -
ADDREss n/r, /r�• // -7079 .
071J1
BUILDING-'ELECTRICAL-PLUMBING-MECHANICAL f r
t
OWNERS
"h:'
PLAN CHECK VALIDATION
EECTRIC'PERMIT FEE;
•27VH PHONE _
CONTRACTORS UTLETS-SWITCHES-RECEP 5.00/1.00TpV
/ '!� LICNo.r.� 01 IM L
CONTRASIGHTING.FIXTURES 5.00/1.00
DRESS offs
AD776 #&SWV � PPLIANCES-RESIDENTIAL .4.00 '
// PHON PANELS 5.00 DATE OF APPLICATION
ORCHDECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR •
ENGINEER 'LIC.No. I SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT '6,QQ PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
' SERVICE CHANGE 10.00
o a LICENSED CONTRACTORS D17CLARATION (/ J
U U 1 hereby affirm that I am licensed under provisions of Chapter 9' ISSUANCE DATE'
H a w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
w z Professions Code nJ Icense is in full force fj ❑ '❑ ❑
Z i w W License Clays fa Can Number_S,7Y_
Uatc_ Contract., _L --,_
y E BUILOINGRERMIT, r' „
a w OWNER-BUILDER DF.CLARA'I'ION "sa:
oA. MISC. REFER TO ORD INFORMATION"`M -
w,; N I hereby affirm that I am exempt from the Contractor's License
FL0 < Law for the following reason.(Sec.703 1.5,Business and Professions PERMIT ISSUANCE 6.00 VALUATION
Code:Any city or county which requires a permit to construct,alter,
rt Q a o improve,demolish,Dr repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
i O u requires the applicant for such permit to Nle a signed statement that TOTAL PERMIT T
wm he is licensed pursuant m the provisions of lha Confrsctor's License l/L
r z r
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
< Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
F.c the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a ;m by any applicant for a permit Subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(1500).):
❑ 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 docs not applyto an owner of
property who builds or improves lhercon.and who docs such work FIXTURES-PER TRAP 4.00 50.FT.FLOOR AREA TOTAL ACREAGE
• mentsam through his own employees,provided that such improve- GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
mems are not ugh his or employee sale.If,however,the building
or improvement is sold within one year of completion,the owner GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE.
builder will have the burden of proving that he did not build or im- PES IND CON Pe Other
prove for Putnam,ofsale.l. INDUSTRIAL WASTE INTER2000
❑ 1,as owner of the property,am exclusively contracting with . .
❑ ❑. ❑ . ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The 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,contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 ' TRACT NO, PARCEL NO.
❑ 1 am exempt under Sea.-,B.&P.C.for this WATER HEATER ADVENT 4.00 '
reason
Owner Data WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK FRS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00 '
I hereby affirm,thatIhave a certificatecfconsent Inself-insure, ZONING ENG.SITE N0.
or a certificate of Workers' Compensation Insurance,or a certified
copy them [& 9 O,I.AE.I
Policy Nn.LA/(4.'/1Company ZERPWAS1
O ❑ -Certified yi1 herehyf ''hed. FIRE SPRINK ENERGY T-24
Z Z LV Certife fled i th ci 'n action division. MISC.- REFER TO ORD.
O Applies.[- - Y ❑ N Y ❑ N❑
F- w PERMIT ISSUANCE 6.00 - FLooD ZONE A.L.U.C.
0 - CERTIFICATE.OF EXEMPTION FROM WORKERS'
IIJ > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
a o (This section need not he completed if the Permit is for one TOTAL Y❑ N❑ Y❑ N❑
0 Z hundred d.11cea(SI00)or less.) _. >:
U O 1 certily that in the performance of the work far which this per. UTY'. . 'ME ANICA ER ` FEE- • FEE SUMMARY
lL - mit is issued,I shall not employ any person in any manner so as o, " •
U. hecome subject to the Workers'Compensation laws of California.
C) GG Date Applicant A' ER OR ADD TO ECH. 4..66 BUILDING
} m NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F-. ? 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(TO 10=C.F.NI) 3.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.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 for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3097,Civ.CJ.
Lender's Name
HEATING UNIT(OVER 100,000 B.T.U.P.50 ELECTRIC
Addr
Lender's Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE), 3.00
. information is correct.I agree to comply with all city and county uction, BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
PLUMBING
ordinances and state laws relating to building constrand
hereby authorize representatives of this city to en ler upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCM. MECHANICAL UO
abase-mentioned property for inspection purposes.
We) agree to save, indemnify and keep harmless the it of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which O CONST.TAX
ma any way,a e against said City in conseyuence of[he PERMIT ISSUANCE 3.00
gra m f1 wa ne, e/S ppCC MaE/C�H.COg.NR }IT I LIC.NO.
Bmyl(y(jfp TOTAL/' _
Si a ore ofA licant Contract r Q� TOTAL;
":;t O�
OFFICE COPY