C 7261 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BO,LMINGr APPLICATION & PERMIT
ADD s L� �1
F LANE BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 7261
OW a3/
ER'S OF ^ PLAN CHECK VALIDATION
NAME `1
AuSSELL t zow-E Lew1 E atsl F82y B
NOAMiBAcroRs UTLETS-SWITCHES-RECEP 5.00/1.00
etv 's,VV.c.No, LIGHTING FIXTURES 5.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
11 CONTRA /' J
7-Li-L- 674ee,44 NONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
OR
hJiWA.rl '-ARCM SIGNS s.00
ENGINEER p Dn T' L/
/l V G.F`r a .N SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION
ADDBESS AION C SS ATE$ SPECIAL CIRCUIT 5.00
SAPD AVE1arQEA1Ry D'l A. zn, I EMP.METER OR POLE INS. 15.00
APPLICANTS 'A4)sUELL LE(0)4 MOTORS SEE FEE SCH. s1"'
ADDRESS
'7507 'aF LA �'A/lCE DRI GUi SERVICE CHANGE 10.00 7 �
OL LICENSED CONTRACTORS DECLARATION 1/'
a Z c I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
v, ¢ w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
o z Professions Code, ny license is in full force aryRdl effect. ❑ ❑
z oz N�-.. License Class_ Lic.Number NZ
o�Fw Dale�jf�. Contractor
M Q w a OWNER-BUILDER DECLARA I p 'PTiGB
MISC.- REFER TO ORD
row .;LL ,nA I hereby alfrm that I am exempt from the Contractors License -
A S/FT.
ruo J Law :Any following reason.ch(See.
req imsa permit
to construct,
Professions PERMIT ISSUANCE 6.00
EwWIA
i Code:Any cityor countywhiny struiresapermiltol»issuance,also O
a ¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC.
i G LL requires the applicant for such permit to file a signed statement That TOTAL
% gNslr TO -ort/4
u,$m he is licensed pursuant p the provisions of the Contractor's License
> Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe �-y
zo Business and Professions Code)or(hal he is exempt therefrom and OTK. •�4^(f- PLUMBING ERMITjoi, a}r`.t F� t�L-L-S p'-
X H the basis for the alleged exemption.Any violation of Section 7031.5 :TT'ntil'-i '+ +" Lsl{SI':a t M,- i c 'h.'i' t.:• STORIES TYPE CONSTR.
n ; by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00 q /
of not more than five hundred dollars($500).j:
❑ I.as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 �_3 %
Code:The Contractor's License Law does not apply to an owner of
' property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve GAS-EA.SVSTEM-1 4.00 OZq
ments are not intended or offered for sale.If,however,the building /
or improvement is sold within ma 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-
prove 1.aso RES IND CON PB Orter,
of sale.(. INDUSTRIAL WASTE INTER. 20.00 El ❑ ❑
O 1,as ownernee of the property,am exclusively Contracting with
licensed contractors to construct the project ISec.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 contractomal licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lumexempt under See. ,B.&P.C.for this oh WATER HEATERW/VENT 4.00 7�c"'rL
Owner
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK FRS'COMPF-NSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate ofconsent to self-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.). �.- I f'•
Policy No. Company th2maai Awd
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified ' py is filed with t y inspection division.
) Applicant s MISC.- REFER TO ORD. YE3 N[3 Y ❑ N❑
~ rn PERMIT ISSUANCE 6.00 FLOOOZONE A.L.U.C.
� CfiRTI FICCO -COMPENSATION
INS FROM WORKERS'
W � COMPENSATION INSURANCE PLG.CONTR. LIC.No. PLG.
CL Z( This section need not be completed if the permit is for one TOTAL Y C] N� Y E] NE]
hundred dollars(S 100)or less.) a710=CF.PA)
nU O 1 certify that in the performance ofthe work forwhich this per-
W 1- mit is issued,1 shall not employ any person in any manner so as to ,Owbecome subject to the Workers'Compernalion LwsofCalifornia. • :Date Applicant ALTER OR AD4.00 BUILDINGCis NOTICE TO APPLICANT: If,after making this Certificate of Ex.
emption,you should become subject to the Worken'Compensation APPLIANCE4.00 PLAN CHECK
provisions of the labor Code, you must forthwith Comply with FEE
suh provisions or this permit shall be deemed revoked. AIR HANDLING 1 ) 3.00CONSTRUCTION LENDING AGENCY AIR HANDLING U .PA) 5.00 SEISMIC FEE 33.1 hereby affirm that them is a construction lending agency for EXHAUST HOO2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
' I certify that 1 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 PLUMBING
ordinances and slate laws relating to building construction, and BOILER-COW(3H.P.or100,DDOB.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. u
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against aid City in consequence of the
granting of this permit. ,,.
MECH.CONT. LIC.NO. MECH. �,. �W �O
TOTAL v ^a�O --
L I
Signature Applic ntracto Date
OFFICE COPY