7135 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
PERMIT NUMBER
BDILDIN. APPLICATION & PERMIT 7135
ADDRESS
,0610 1 4Z -232 BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
O.HER'S PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
• NE
CONTHALTOH'6
�{
NAME G / UTLETS-SWITCHES-RECEP 5.00/1.00
/ - 256Zetjn L.c.No. 2 rrG LIGHTING FIXTURES 5.00/1.00 r
co"rRAcrons /� _APPLIANCES RESIDENTIAL 4.00
ADDRESS C
'HONE PANELS 5.00 DATE OF APPLICATION
ORRCHITECr SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC No. SIGNS TRANS. 3.00
ADD cis ON ENG. SPECIAL CIRCUIT 5.0D PERMIT VALIDATION
zlv rrEMP.METER OR POLE INS. 15.00
APPLICANT 6
nROPE ss MOTORS SEE FEE SCH.
1
SERVICE CHANGE 10.00 tt /yy�S
r
' w w o LICENSED CONTRACTORS DECLARATION
u U I hereby uffrm that I am licensed under provisions of Chapter 9 - ISSUANCE DATE
G m (commencing will,Section 7000)of Division 3 of the Business and . BLDG. ELECT. PLG. MECH.
Professions Code, it t nerve is in full form e `,q G ❑
z i= Licence CI' Lic.Number / ❑
Q m F Uatc professions
m J / ''FBUILD t1G PERMIT
a a OWNF;R-BUILER DECLARATION
E: O a" MISC.- REFER TO ORD INFORMATION
S A. r I hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
Fu04 law for the following reason,(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00
COLIC:Any city ore ulty which requirest permit to construct,alter,
2 improve,demolish,or repair any structure,print la its issuance,also ELEC.CONTE. LIC.NO. ELEC.
le
iL m LL requires the applicant for such permit to file a signed statement that TOTAL -,f7 PERMIT TO
w he is licensed pursuant to the provisions of the Contractor's License
H z i
I...(Chapter 9(commencingwith Section 70000of Division 3 ofthe -�
x o Business and Profassions Code)or that he is exempt therefrom anti OTY. PLUMBING PERMIT FEE
EE H m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant Toru permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(5500)J:
❑ I,as owner of the property,or my employees wish wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the st ructu rc is not
intended or oRkred In, sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,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.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such int prove
ments are not intended or offered tier sale,if,however,the building GAS-EA.SYSTEM-1 1 INC.4 OUTLETS 4.00
or improvement Is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 (EA.) 100 BUILDING USE
builder will have the burden of proving that he did not build or im- . . .
RES IND CON PB o,M1er
r prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
;k CII,as owner of the property,um exclusively contracting with ❑ E] C] E] ❑
licensed contractors to construct the proicet(See 7044, Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:'1'he Contrnaor'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 crntractons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I ant exempt under See.-,BAD C.for Ibis WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSA1 ION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a Curtilwate of consmd to AtGinsure, ZONING ENG.SITE N0.
or a certificme of Workers'Compensation Insurnnce,or a certified
copy thereof(See.3800.LabC I
Policy No. Company .1esyT
O ❑ Certified copy is hereby furnished. RE SPRINK ENERGY T-24
Z Z CeRthe opy tiled wish the rt ns sect ion division.
Q p cauls✓D �L7�/� MISC.- REFER TO ORD. Y❑ N❑ v ❑ N❑
IrN CER'I'11'ICA'IEOPI:XEMPI'ION FROMWORKP-RS' PERMIT ISSUANCE 6.00 FLOOo zoNE A.L.U.C.
LU > COMI'IiNSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL 0 (,'tris section need nor be completed if the permit is Iia u TOTAL Y❑ NEO] Y E] NEI Z
hundred dollars($100)or Itrel.
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
L H aril is issued, I shall not employ any person in any manner so as to
U become subject to file Workers'Compensation Laws of California. BUILDING
G. Dam Apph°ant ALTER OR ADD TO MECH. 4.00
}
To NOTICE 10 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 strait be declined revoked. AIR HANDLING UNIT(TO 1O)D00CF.M.) 3.00
CONNI'RUCHON LENDING AGENCY AIR HANDLING UNIT(OVER 10MIC.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 far which this permit is issued(Sec. MICROFILM
3097,Civ.CJHEATING UNIT(TO 100,000 B.T.U.) 4.00.
Lender's NameLeader's Address HEATI NG UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lc.
1 certady that 1 have read this application and slate that the above VENTILATION FAN (SINGLE) 3.00
• information is correct. I agree to comply with all city and'a my PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP I3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,0008TU15EE FEE SCH. MECHANICAL
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 CONST.TAX
may in any way accrue against Said City in consequence of the PERMIT ISSUANCE 3.00
flIgrMn permit MECH.CONT. LIG NO. MECH.
r TOTAL TOTAL
gra
Igo urea pplicant/Contractor Date
INSPECTOR COPY