7081 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT 7OS1
ADDRESS pp,/ S �LANty AJc "-
O0 '1 BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'5 PLAN CHECK VALIDATION
NAME fj yM�/ �f^, OTY. ELECTRIC PERMIT FEE
CONTOR / PHONE / /V
NAME Tons OUTLETS-SWITCHES-RECEP 5.00/1.00
AME
LIC.rvo. LIGHTING FIXTURES 5.00/1.00
CONTRACTOR S
ADDRESS 770 C)9657-.J 0T 5r APPLIANCES-RESIDENTIAL 4.00
` PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS - 5.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADD ESS esc. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00 {
ASMOTORS SEE FEE SCH.
ADDREDDRESSS _
SERVICE CHANGE 10.00 911 if
Coca,o LICENSED CONFRAC-FORSDECLARATION
v u I hereby affinn'that I an,licensed under prcom....S of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
ri 1'mfesVluns Code,and I licenx is in full force d U 9Z F"�
Z o - Licmtre CIu3s�Lin.Number ❑ ❑ ❑ 13r
mI- w Uatc_ Cnnlraclor A}.�
m¢ ¢ OWNER-BUILDER DECLARATION BUILDING PERMIT
_ an INFORMATION
O d U MISC.- REFER TO ORD
E
; N Thereby ul❑nn that I am exempt from the Contractor's License
F LL o Q Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 6.00 VALUATION $/FT.
s Code:Any cilyorcounty which requires a permit to construct.alter,
ce a¢ o improve,demolish,or Lerner any structure,prim to its issuance,also ELEC.CONTE. LIC.rvo. ELEC.
U. requires the applicant for such permit to file a signed statement that TOTAL PERMIT T
d w m he is licensed pursuant to the provisions of the Contractors License
H z a
Law(Chapter 94mmmencingwilh Section 7000)of Division 3 ofthe ML
Business and Plufessiuos Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
u , by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
.1 Put more limn five hundred dollars(8500).):
❑ h as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their Vole compensation,wIII do the work,and the st ruclure 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.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improse-
Rents are not intended or offered for sale.If,however.the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,tire owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that Ire did not build or int-
provefor purpose ofsae.). INDUSTRIAL WASTE INTER. 20.00 RES IND CON RB One,
❑ I,as owner of tire properly,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct it" Project ISec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:"I'he Contramor'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
• aete
ntm .u%License
. Law.with acontructorlS)licenmR."
Lint puumm
I the Cor,, clR such
SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
'
❑ 1 am exempt under Sec. .B.&P.C.for tills WATER HEATER W/VENT 4.00
reason
Owner Date/ WATER SYSTEM 4.00 ACC.DATE ACG FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that 1 have a certificate of consent to mlLinsure'
or a certificate of Workers Compensation Insurance,or a certified ZONING ENG.SITE N0,
copy thercaj(Sec.3800,Lab C.).
Policy No."6,!J�C nlpany�Xl QXfs�.
❑ �enilicd cop rebx fumes - FIRE SPRINK ENERGY T 24
`Z Z f:I/Clcn ificd col I@iQ} wltN c 4S
c'an division.
O Appicunt_Ir B /4sa MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
M w CER'IIFICA'rp OP EXEMPTION 17ROM WORKERS' PERMIT ISSUANCE 6.00 FLOODZONE A.L.U.C.
W > COhIPENSAI'ION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O Illus section need nut be completed if the permit is for one ITOTAL Y❑ IN El Y❑ N❑
Z) Z h undmd dollurs is 100)or lcss.l
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,1 shall not employ any person in any manner so as to
U bee ulnc subject to the Workers Compmisation Laws of California.
ED Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} rn NOTICE'1'0 APPLICANT: If,after making this Certificate of Ex-
Z_ Cnlption,YOU should becume subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you most I..thwith comply with FEE
C) such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 101MC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIRHANOLING UNIT(OVER 10MC.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the lurfornnance of the work for which this permit is issued(Sec. - MICROFILM
3097,Cic.C.L HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATINGUNIT(OVER 100,000 B.T.U.)7.50
Lender's Andreas 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 state 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 eater upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL O�
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 whichCONST.TAX
may i y way accryte against said City in consequence of the PERMIT ISSUANCE 3.00
grantin of i enmL MECH.CONT. LIC.NO. MECH.
{rr TOTAL
Slg�re�AppFcant/ Dn cor TOTAL 'O(�
INSPECTOR COPY