C7247 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT lDENTIFICATION PERMIT NUMBER 2` APPLICATION & PERMIT
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Ess BUILDINGDIrvO
ADOR74
/L �� BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
'OWNER'$ /I PLAN CHECK VALIDATION
NAME y T �/G �1yxL �/ C ITV. ELECTRIC PERMIT FEE
Bob T k/IANe &i 1` PHONE 41*_02,. O
No MFRACTORs OUTLETS=SWITCHES-RECEP 5.00/1.00
(Z uc.rvD.3FS�-7la LIGHTING FIXTURES 5.00/1.00
CON TRACTOR'S 55 Ci51o1C/ APPLIANCES-RESIDENTIAL 4.00
ADDRESS
3' . �f4 aPHONE l PANELS 5.D0 ITJ. DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.G NO.
O
OR
ENG Cf
-41,1C No No. SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION
AD0or$$ SPECIAL CIRCUIT 5.00
1�0 '- ozld.'I�I EMP.METER OR POLE INS. 15.00
APPLI L MOTORS SEE FEE SCH.
ADDRESS
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NILE' a5 Q. SERVICE CHANGE 10.00 (�
woo LICENSED CON TRACTORS DECLARATION
rt u 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w (conmtencivg with Section 7000)of Division 3 Of the Business and BLDB. ELECT. PLG. MECH.
mi 1'mfesssons ' ,and my license i4 in full forge m cfl'1
Licen`C.a> Lie.Number 1 of
o y H Date 1 U Contract., /
a m E BUILDING PERMI I
Ix Q OWNER-BUILDER DECL1RANON INFORMATION
oa MISC.- REFERTOORD
E:
B r 1 heneby minor that I ani exempt from the Cconmetor's License
F a• 6oj Law for the lkdlowingnvsvn.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00 VALUATION SIFT.
Code:Any city or county which requires a permit to Construct,allet, /�¢OUOr
QQ Q Q mImprove,demolish,or repair any Structure,prior to Its Issuance',also ELEC.CONTE. LIC.NO. ELEC.
o ¢ ipdres the applicant for such permit to file a signed statement that TOTAL
a w y he is licensed pursuant Os the provisions of the Contractor's License ` PERMIT TO
H Z >
Law(Chapter 9(commencing With Section 7000)of Division 3 of the
< Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE v I/ry V
r the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
v � _ by any applicant for a permit subjects the applicant to a civil penalty mALTER-DRAIN -WATER (EA.) 4.00 2 1_1A� /1K7j�J
of nut ore than five hundred dollars($500)J:
O I,as owner of the property,or my cmpl0yces with wages as BACK F LOW PROTECT.DEVICE 2.00
their sole compensation,will do the work,and 0t.structure is not OCC.GROUP RES.uNlrs
/CC
intended 0r offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,GOND. 4.00
Cud,The Contractor's License Law does not apply to an owner of /
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 G• so.FT.FLOOR AREA TOTALACRPACE
himself or through his awn employees.provided that such improve-
mentsarenotintendedorofferedforsale.If,however.the building 1 GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00 Q.,
r improvement is sold within one year of completion, the owner- GAS EASYSTEM-OVER 4(EA.) 1.00 i BUILDING USE
builder will have the burden of proving that he did not build or it.- - . IND CON PR Om.,provctor p......of sale.L INDUSTRIAL WASTE INTER. 20.00 ❑ 1:1 ❑ 1:10 h a owner of the property,am exclusively contracting with
licensed co meta rs to construct Dm project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 1 ASSESSORS PARCEL NO.
and Professions Code: ty Conbuilds s License Law dues not apply n ^- ` ' /
to tr owner of property who builds tr improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 ✓5!/Iq-A�' ^a-1
contracts for such cenjec is with a aantmclorts)licensed pursuant to
the ContraaOr License Luw. � / ,. � SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lamexcmpftmder Scc. ,B.&PCfu this WATER HEATER W/VENT 4.00
reawn
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKHRS'COMPI'NSA'IION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate o fecameit to self-insure. ZONING
or a certificate of Workers ifi
Compensation Insurance,or a certed 1 I : I ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.)'t )SF�� ( " 1
Policy No. Company
O ❑ Cenilied cup,'is hereby furnished. C FIRE SPRINK ENERGY T24
Z Z fy Certifes`��_oqY��is tiled with the city inspvOmm'divi,mr.
O Applicant_`L.[.je 6T,C2 `: MISC.- REFER TO ORD. Y❑ N❑ Y ❑ IN C]
cc: Lo CER'I1171CA117017 FXEMP1'1ON FROM WORKFRS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.C..
LL > COMPENSATION INSURANCE PLG.CONTR. ❑C.NO. PLG. f
CIL 0
I"Phis section need nut be completed if the pit rnHit is for one TOTAL �. Y❑ N❑ Y,a IN[J
Z) Z hundred not an 1$100)o,less.)
U O 1 certify that in the performance of[lie work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mit is issued,I shall not employ any person in any manner sn as IN
U beconic subject to lire Workcrs Cmnpensation Laws of Califontia.
EQ.D Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} N NOTICE.TO Al'I'LICAN'I': If,after nicking this Certificate of Ex-
F ? C optlnn,you should become sable"to the workers Compensation APPLIANCE 7 - 4.00 PLAN CHECK /
provisions of the Labor Code,you must forthwith comply with FEE
U such pmvNions or this permit shall he deemed revoked, s AIR HANDLING UNIT(TO 10=C.F.IV0 3.00
CONSTRUCf10N LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE 5
1 hereby affirm that there is a construction leading agency for EXHAUST HOOD (WITH DUCT) 2.00 /
the perfonnonce of the work for which this permit is issued(Sec MICROFILM
3097,Civ.C.), NOh� HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name. HEATING UNIT(OVER 100,000 B.T.U.)7.50 o
Lender's Address ELECTRIC !) O
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
. indinnmis n correct I agree to comply with all city and coonlyand BOILER-CDMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING /
ordinances and state laws rating to
to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE F E E SCH. MECHANICAL a 8.
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 PERMIT ISSUANCE 3.00 CONST.TAX
ru
may in any way acce against said City in consequence of the
anting of fir is Peter' MECH.CONT. LIC.NO, MECH.
N lU 1 TOTAL TOTAL
Signature O Applicant outractor Date 1 xa,
x INSPECTOR COPY