C7077 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FICATION PER IT NUMBER
I;
ADDRESS APPLICATION & PERMIT 7U77
1 AooaESs O� Q � n�Z T ,/I�� BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNEN'S a d /` J7 LAN CHECK VALIDATION
Ji
"All PTY. ELECTRIC PERMIT FEE
C 17 JZ)
U PRDNE
CONTHACTOR _
rp, S UTLETS-SWITCHES-RECEP 5.00/1.00
f' NAMl �/
t T// #EnrlA LIC.NG LIGHTING FIXTURES 5.00/1.00
4DDFE OToas APPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE .22976 PANELS 5-00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
' LIC,Nov SIGNS TRANS. 3.00
ARCH,ss E "G' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
/ APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
r
02. LICENSED CONTRACTORS DECLARATION o
_Q is u I.hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE '
N Z-.w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F v,z 1'rcllessions Code, nil 1 license is in full force q��f(ct. ❑ ❑ ❑
Z 0 - 1-icense Class hie.Number 4`
O Salty Dulc�Y-�/- Contractor d�E�_
r
Y�,� ;. .. BUILDING PERMIT
Q'w eft .x, ..OW R BUILDER DECLARATION«A.
o "-?• 'fir INFORMATION
w';LL H I herchy affirm ilial I am exempt front the Contractor's license MISC-• REFER TO ORD
u o j Luw liar lire following reason.(Sec.7031.5,Business and Pndeseinns VALUATION SIFT.
� _ PERMIT ISSUANCE 6.00 $
r Em-� Code.Anycilyorcounty which ulquiresa permit to construct,libel, ELEC.CONTR. LIC.NO.
ic m a O improve,demolish,or repair any structure,prior to its issuance,also ELEC.
0 LL requires the applicant for such permit to file a signed State'me'nt that TOTAL PERMIT TO
A w er he is licensed pursuant to lire provisions of the Contractor's License 1
F z i Law Wimple,9(commencing with Section 7000)of Division 3 of the
a Business and Professions Cale)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE ,
K F Oo the basis for the alleged exemption.Any violation of$eclion 7031.5 STORIES TYPE CONSTR.
w. !2 by any applicant Turn permit subjects the applicant toacivilpenalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(S500)J:
0 1,as owner of the property.or my employees with wages as BACK FLOW PROTECT.DEVICE 2,00 OCC.GROUP RES.UNITS
their stile compensation,will do the work,and the structure is not
intended or offered for Is (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law docs not apply to an owner of
properly who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 SO,FT.FLOOR AREA TOTALACREAGE
® himself or Duough Itis own employees,provided that such in,ove-
nrcntsarenutintendedorofl'Crud for sale if,however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) LOO BUILDING USE
huiWcr will have the burden of proving That he did not build or ire' RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 El 1:1 El El ❑
0 Las owner of the property,am exclusively 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 Contractor's License Law does not apply
to an owner of.properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
mntruets for such projects with a contrucmds)licensed pursuant to
tie Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
Cl I am exempt under Sec. ,BAP.C,for IN, WATER HEATER W/VENT 4.00
fl 1111
Owner Date WATER SYSTEM 4.00 ACG DATE ACG FILE NO.
WORK I!RS'COMPENSA"I]ON DECLARATION WATER TREATING EQUIP. 4.00
1 hereby atfirn.that have a cortiticate of consent to sell'-insure, ZONING ENG.SITE NO.
Or a certificate of Workers'Congren,,Ihm Insumner,or a certified
copy Cher of(S�e� �3t800 1ab.C.) C -Sar
Policy N efor-r�' t ny-4 A i -P[Ael SC
O C� Ified opyli hereby fro hal' FIRE SPRINK ENERGY T 24
'z Z L'✓C`rt ific Y�s OIuJ�r3l0t thA eit nspection division.
-O"' APPhcm `vYYY111 oV:. 1,GJ - _.. MISC..; ;.�, R_E FER__TO ORD. _a. _ Ty: ME]ME] .:Y.❑ N❑
CC y CERTIFICATE OF Exlim rON FROM WORKERS' T" PERMIT ISSUANCE ' 6.00 FLOOD ZONE A.L.0 c.
LLQ COP1ITNSA'I'ION INSURANCE PLG.CONTR. LIC.NO. PLG. Y❑ NE] ` Y❑ NE]
CL Z ('Phis section Icen
CL a d ot be cont..luted if the permit is for of TOTAL
hundred doll...($100)or Ie"9) L
U O 1 certify that in the pertnnnunce of the work for which this per. CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H nail is issued,I shall not employ any person in any manner so as to
V beemee sobject to the Workerx'Coml pcnsution Law,of California.
a Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} DO N(yl'ICI' TO APPLICANT': If,after making this Certificate of lix-
F 2 eruption,yooshould become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of"the Labor Code, you must forthwith comply with FEE
L) such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10):) QF.M.) 3.00
CONSTPucrION LENDING.AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
lire pati rmance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). / HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Addo,
H EATI NG U N IT(OV ER 100,000 B.T.U.17.50 ELECTRIC
ss
I certify the 1 have.read this application and style that the above VENTILATION FAN (SINGLE) 3.00
{nforolalion is correct. I agree to comply with all city and county PLUMBING
ordinances and slate laws relating to building construction, and BOILER-71M ,H.P.or100,000B.T.U.) 4.00
hereby authorize representatives of this city to enter upon Om BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above mentioned property for inspection purpose'.
(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 i any way accrue against Said City in consequence of the PERMIT ISSUANCE 3.00
grand this perms. MECH.CONT. - LIG NO. MECH.
_ _ DTA` TOTAL
Signa an/C n sec Uate //u,rrti�[. p����
INSPECTOR COPY