7144 (3) APPLICATITO FILL IN INFORMATION WITH(N RED LINES - USE BALL POINT PEN ONLY
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BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
"mG APPLICATION & PERMIT
7144
Ao.m.s
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL i
,.
onsmEwe PLAN CHECK VALIDATION
NAME V. ELECTRIC PERMIT FEE
PHONE
�-
NAMER"o S - OUTLETS-SWITCHES-RECEP 5.00/1.00
C, LIGHTING FIXTURES 5.00/1.00 ,
cory c o _ PPLIANCES-RESIDENTIAL 4.00
Aoo Ess
L QS HorvE ' PANELS . 5.00 DATE OF APPLICATION
is
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
Llc.NO. SIGNS TRANS. 3.00 '
ADDRESS G.EN5.00 PERMIT VALIDATION
z TEMP.METER OR POLE INS. 15.00 7
APPLICANTS MOTORS 1 - SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
wO o LICENSED CONT RAC'I ORS DECLARATION
G v U I hereby affirm that I am licensed under provisions of Charter ISSUANCE DATE
w a N (Commencing with Section 7000)of Division 3 of tae Busin a BLDG. ELECT. L MECH.
F N Z Professions Code,and my license is in full fare ❑ ❑ ❑
Z D - Lic Ise a Lic NumM1cr
o Z r Da 5�{--p -Contractor
V, EV �-/ BUILDIN PER IT
¢ rt w ¢ OWNER-BUILDER DECLARA I
D INFORMATION
A o A MISC.- REFER TO ORD
w 3 a- H I (for the
affirm that I ant exempt from the Contractor's License VALUATION S/FT.
F LL o a Law for the following reason.(Sec.70715.Business and I'rol'essians PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to construct,alter,
2a,¢ improve,demolish.or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.rvo. ELEC.
O
' ¢ requires the applicant for Such permit to file a signed stalemenl that TOTAL PERMIT TO
'w m°' Ile is licensed punuant to the provisions of the Contractor's License
FZi
Law(Chapter 9(corn me Acing with Section 7000)of Division J ofthe
- a Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
F p the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
Ic aim by any applicant for a permit subjects the applicantto a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of nut more than five lmndred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2,00 OCC.GROUP RES.UNITS
their cele Compensation,will do the work,and the 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 dots not apply to an owner of
properly who builds ar improves thereon,and who does such work FIXTURES-PER TRAP 4,00 sa FT,FLOOR AREA TOTAL ACR EAGE
himself or through his own employees,provided that such improve.
ments are not intended or offered for sada If,however,the budding GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or ice- IGAS-EA.SYSTEM.OVER 4(EA.) 1.00 BUILDING USE
prase for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 RES IND CON PB Doer
❑ 1,as owner of the property,am exclusively contracting with E] E3 ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
.all Professions Code:The Contractor'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 projecis with a conlractoos)licensed pursuant to
the Contractor's license Law. - SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exemplunder See ,B.&P.Chlr this WATER HEATER W/VENT 4.00
rl'asall
Owner Dale - WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPFNSAT'ION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that 1 have a Certifica a o'c moot to sel&insure' ZONING
ora a c of Worker'Compensaf a I s ra On a codifier ENG.SITE NO.
Ityy�xl
). is dFIRE SPRINK ENERGY T-74
wt ly di i. n
z p AVPlican ` MISC.- REFER TO ORD. v❑ NE] Y ❑ N❑
jr rn II`ICA"Iii 01'HXFMVI'ION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE ,A.L.u.C.
W CCMPFNSATION INSURANCE PLG.CONTR. LIC.NO. PLG,
CL 0 z lis section ,evil not he completed if the permit is for one TOTAL V❑ N❑ V❑ N❑
hundred dollars(S I OO)or IessJ
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I-• nut is issued,I shall not employ any person in any manner so as to
0•U become subjecno rs lire WorkeCompensation laws of California.
ED Date n licant BUILDING
a pp ALTER OR ADD TO MECH. 4.00
} on NOTICE 70 APPLICANT: If,after making flus Certificate of hx
~ Z_ vo,tion,you should become subject to the Workvo,Compensation APPLIANCE 4.00 PLAN CHECK
provisions of tire Labor Code, you must forthwith comply with FEE
;;i U such provisions or this pemait shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONS'fROC`rION LENDING AGENCY AIR HANDLING UNIT(OVER 10000C.EM.) 5.00 SEISMIC FEE
I herehy.affinn that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the peflonnance of the work her which this permit is issued(Sec. MICROFILM
3097,Civ.C.T HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
lenders Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC 1
1 certify that I 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 stale laws relining 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
above-mentioned properly for inspection purposes. BOILER-COMP (Over 100,000 BTU(BEE FEE SCH. MECHANICAL
(We) agree m 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
n in any way accr a against vid City i onsequence of the
ra tirtg of thispCONT. LIC.NO. MECH.
g TOTAL TOTAL
1 t,lu c f 1p1 c 1 / out actor ata -
INSPECTOR COPY
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