7183 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BDILDING APPLICATION & PERMIT 7183
y DDItCS
/y $ BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
UP f7 `' I-,- cre-q III-OW R'S • PLAN CHECK VALIDATION
NAME/�� QTY. ELECTRIC PERMIT FEE
CONTRACTORS UTLETS-SWITCHES-RECEP 5.00/1.00
NAME
5i�rr ,1,,:,S uc.No. LIGHTING FIXTURES 5.00/1.00
rONTRACTORS APPLIANCES-RESIDENTIAL 4.00
� AOOREss
S PHONE 7757-10&CPANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6-00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
Sac,NO. SIGNS TRANS. 3.00
ARCH.ORENG, SPECIAL CIRCUIT $QO PERMIT VALIDATION
ADDRESS ,
ZIP EMP.METER OR POLE INS. 15.00
APPLICANT 9 MOTORS SEE FEE SCH. / J'
ADDRESS
SERVICE CHANGE 10.00 y/
w p o LICENSED CON'I'RACfORS DECLARATION
u U I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
y G w (commencing with Section 7000)of Division 3 of The Rosiness and BLDG. ELECT. PLG. MECH.
r N z 1'raliseions Code a nd W license,is in full force u d eIT
z o m - License luss_�1Z Lia Number3.Ek ❑ ❑ ❑ \ ❑
o t Date s.-e Cnmraclors�'«_�_ T
a y f .�, BUILDING PERMIT
rt w 4 OWNER-BUILDER DECLARATION. x INFORMATION
0d ° MISC.- REFER TO ORD
w 3 LL r hereby vffinn thm I ran uxenhpt from the Contractor's LieWnse VALUATION' S/FT.
.. o j Law lie Lite following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6,Q0
� - Code:Any city or county which requires a permit to construct.alter, J7 0D
EE to improve,demolish.or repair any'structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
ii: 0o u rgwres the apphcanl for Such pg10(Ile a signed statement that TOTAL PERMIT TO
A w m lie is licensed pursuant to the provisions of the Contractors License
F z i Law(Cimpter 9(,uRRoc cingwith Section 7000)of Division Solthe P.<&?C4 r W*LG._
srBusiness and Profeasiore Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ � 0 the basis for the alleged a xemption.Any violation ofSection 7031.5 - STORIES TYPE CONSTR.
a „- by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER IEA.) 4.00
of not mom than five hundred dollars(5500)): y
❑ I,os owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 DCC.GROUP RES.UNITS
Their side com pens:dion,will do the work,and lite 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 does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 - so.PT FLOOR AREA TOTAL ACREAGE
. himsell or through his own employees.provided that such in.Pmve-
mentsire not intended oroffered for sale.if,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
or improvemew is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden o1'proving that lie did not build or im-
IND
proveforpurposeofsale.). INDUSTRIAL WASTE INTER. 20.00 RES_ El CON PB Omer
❑ I,as owner o1'the property,am exclusively contracting with 1:1 ❑ ❑ ❑ ❑
licensed contractors to construct the pmject(Sec. 7044,Business LAWN SPRINKLERS- 1 INC5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Con ractor's License Law does not apply
To an owner of property who builds or improves toreon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
cantructs IRE such projects with a CORODIClaf(51 licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lamoxcmptundersee. .B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK E RS'C'OM PENSA'I'ION DECLARATION WATER TREATING EQUIP. 4.00
Ih,.by affirm that l have a ceniflcaleof Con.Ht tOSCIf-IIISurs. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a cerlifteJ
copy thereof(Sec 38/X),Lab.C-.)) r
Policy Ni Cam,any ROa"'�C 'S'r
Ll Cenilhi,hereby FIRE SPRINK ENERGY T-24
F Z ❑ CcrtihCJ �s/Olcx Ihc_cjry`nsnectian division. MISC.- REFER TO ORD. Y❑ N❑
O Applicant Y❑ N❑
Com. Li 6�aI
le
cc CERTIFICATE OF EXEMPTION FROM WORKERS, PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.C.
lIJ > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CIE. 0� Z (this section eed not he completed if the permit is for one TOTAL Y❑ N❑ Y❑ NE]
hundred dollars IS 100)or less)
U O_ 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued.I shall not employ any Person in any manner so as to
OO become subject to the Worker:Compensation Laws of California. r•yI
w
n Dale Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} W NOTICE'f0 APPLICANT: II',alter making this Certificate of Fx_
F- Z eruption,you should become subject to the Workers'Compcnvtion APPLIANCE 4.00 PLAN CHECK / 7 1
provisions of Ute labor Code, you must forthwith Comply with FEE b
U ,such provisions or this permit shall h deemed revoked. AIR HANDLING UNIT(TO IOpODC.F.M.) 3.00
CONSIRUCfION LENDING AGENCY AIR HANDLING UNIT(OVER l0J0000.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency lot EXHAUST HOOD(WITH DUCT) 2.00 -
the performance ol'the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address H EATI NG UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I certify that I have read this application and state that the unovC VENTILATION FAN (SINGLE) 3.00
imonnation is correct. I agree to comply with all city and county PLUMBING
ordinances and stale laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Ogo,10E)POOBTU1 SEE FEESCN. ,MECHANICAL
above mentioned property for inspection purposes.
(We) agree to Save, indenmify a keep harmlew the City of MISC.- • REFER TO ORD.
Cupertino a 'est liabilities,judg s, Costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in it.
way accrue ga'n d City in consequence of the
granting permit. ' MECH.CONT. LIC.N0. MECH.
.l64rLC 2 JABS_ TOTAL TOTAL Ij ��
nature of pplicanl/C nlraclor Date
INSPECTOR COPY