7297 APPLICANT TO FILL IN IN FORMA ION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJEC DENTI FICATIO .PERMIT NUMBER
BUILDING APPLICATION & PERMIT 7��J 1
IDORE40A L,
/ UILDING—ELECTRICAL—PLUMBING—MECHANICAL
0 ER ' PLAN CHECK VALIDATION
ry ME Y. ELECTRIC PERMIT FEE
. PHONE
Acrons
N UT
-SWITCHES-RECEP 5-00/1.00
LIC NO LIGHTING FIXTURES 5.00/1.00
:o i TOIs' APPLIANCES 4.00
A
.' AePi
NIo PANELS 5.00 GATE OF APPLICATION
ARmnTEC SIGNS 6A0 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS Ervc' - SPECIALCIRCUIT 5,00 PERMIT VALIDATION
zIP TEMP.METER OR POLE INS. 15.00
P ANT s n/� MOTORS SEE FEE SCH.
)ZWEss (//,�/Q
SERVICE CHANGE T"" 10.00
0 0 o LICENSED CONTRACT RS DECLARA'1'10 d O
c v U I hereby affirm that 1 am licensed under provisions of Chapter ISSUANCE GATE
H a u (commencing with Section 7000)of Division 3 of the BUsineas d SLOG. ELECT. PLG. MECH.
H�z 1 rot s'wns Cod ad n 'cense h in full force,ur a -
z O m I h sn cfJarvi
ss LicNumb•r_ �• ❑ ElO R U t fey. CnntreUor
a, s'M J BUILDING PERMIT
. ¢ ¢w ¢ OWNbR-BUIL
1`16"
o INFORMATION_
woA - MISC.— REFER TO ORD
3 u H I hereby affirm that I am exempt liom the Ct ntra t •v LiC nsr VALUATION
F .. o sc Law for the foll h g.resson.(See.7031.5,Business and Professions PERMIT ISSUANCE 6.00
o Code:Any city'eha:nunty which requires a permit to c0nslruct.alteq
Qa Q 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
or E m u requires lite applicant for such permit f0 file a signed alatcmcnl that TOTAL PERMIT TO
u whe is licensed pursuant to the provisions of the Contractor's License
FiQ
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
E 4 O Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ I-o the basis for the alleged exemption.Any violation of Section 7031.$ STORIES TYPE CONSTR.
ate _ by any applicant for a permit subjects the applicant ma civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars I S500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP REB.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
COAe:'The Contractor, License Law does not apply to on owner of
pnlperly w1m hallds Or Improves tire..on,and who doc.,Sact,work FIXTURES-PER TRAP • 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• hnnself or through his own employees.provided that such improve
recuts are not intended or offered for sale,lL hnwCvcr,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
or 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 im-
proveFor Purpowofsal,)' INDUSTRIAL WASTE INTER. 2000 RES/IND CON PB Omer
O 1,as owner Of the property,um exClusivcly 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 Contractors License Law does not apply
m an owner Of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects lith a contructodo licensed pursuant to
the Contractor's License Law? SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
Cl I am exempt under Sec. ,B.AP,C.fur this WATER HEATER W/VENT 4,00
mason
OwnerDate WATER SYSTEM - 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPEN5ATION DECI. RATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate Of cr hunt to s,Ifin, re, ZONING ENG.SITE NO.
or n cctlilic 1 n'N'Orkcrs•Compcnsvl ion I s ante or u e,r ial
copy titer' • ' 0,Lab.C.1- _
Policy No. uhnPdny
O O Cc.I ificdcopy;is hereby ishe . FIRE SPRINK ENERGY T24
Z Z Curlifi• op is til h the r Y spr Lion division.
O Ap ,t..,,ht MISC.-' REFER TOIORD. Y ❑ N❑ v ❑ N❑.
~'rn PERMIT ISSUANCE - d :6.00 �-FLOODZONE A.L.11.c.
c'];`; Clp ❑j1f 3110 EXEh11'TIO� Plt)M W R
-W ,CO3MPENSATION.INSURANCI: s •*j' PLG.CONTR. LIC.No. PLG,
CL Z (Ibis section need not be completed if the permit is for'.., TOTAL Y❑ NEI v E] No
hundred dollars(S 1001 or Icss.)
U O 1 certify-that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE, FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in any manor,m as to
O become subject to fit,Workers''Compensation Laws Of Califomia.
a UareApplicantALTER OR ADD TO MECH. 4,00 BUILDING
} m NOl'ICI: '1'0 APPLICANC If,alter making this Certiftnate of Es-
F ? enhption,you should become subject to the Workeri 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 10SMC.F.M.) 3.00
C'ONST'RUCTION LRNUING ACENCY If AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SMICFEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.0
the Peforniance of the work for which this purmit is issued(Sec. ICROFILM
3097,Civ.C.). f, HEATING UNIT(TO 100,000 B.T.U.) 4.00
cndcr's Name
Lcndcr's NameAddress HEATING UNIT(OVER 100,000 B.T.U.)7.50 CTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct.1 agree to comply with all city and county� BOILER-COIuIP(3H.P.or 100,000 B.T.U.) 4.00 PLUMBING) Ordmatmes and stale laws relating to building construction. and
hereby maho,ae representatives of this city to enter upon the BOILER-COMP (Over 100,000BTU)SEE FEESCH. MECHANICAL
m
above- entioned property for inspection purposes. y �-
(We) agree to Save, inde�rt vify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabiliti lodgments, costs and expenses which NST.TAX
may ' any w' actor again I said Chly in Consequence of the PERMIT ISSUANCE 3.00
nh oft I CONT. LIC.NO. MECH.
TOTAL TOTAL
or of Appli nt/Contractor Date
INSPECTORcopy