7284 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 7284
ADORESS
QQ BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAMF U QTY. ELECTRIC PERMIT FEE
C I� s PHONE
CONTRACTORS UTLETS-SWITCHES-RECEP 5.00/1.00
N E
LIC.Nd-;J30 9%7 LIGHTING FIXTURES 5.00/1.00
roNTRoms APPLIANCES-RESIDENTIAL 4.00 '
avoRE qq / � `](
PHONE 76 _&1IS PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.D0 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
1t, LIC,No. SIGNS TRANS. 3.00
ADDRESS ENG. �1. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
1� ZIP TEMP.METER OR POLE INS. 15.00 ��
APPL ICANT's MOTORS SEE FEE SCH.
ADDRESS X11-\ 1 LL1
SERVICE CHANGE 10.00
0 0 o LICENSED CONTRACTORS DECLARATION
a v U I hereby iffnm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
m G u (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F D Z Professions Cod•,and my license is in full force and effect ❑ ❑ ❑ ❑
' OL ; License 'lass ic.Number O
Q w Uum Conhactor_ ,r
BUILDING PERMIT
Q w a OWNER.BUILDER DECLARA'I ION INFORMATION
oa " MISC.- REFER TO ORD
1 hereby affirm that I am exempt Gam the fontrad or's License VALUATION $/FT.
u_ O 4 law for the following reason.(See,7031.5,Businessand Professions PERMIT ISSUANCE 6.00
ih Code:Any city or county which reyuireso permit loconstruct,alter,
pimprove,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
E O LL requires the applicant for such permit to GIC a signed Statement that TOTAL PERMIT TO
A w m he is licensed pursuant to the provisions of the Contractor's License
z i
Law(Chapo,9(commencing with Section 7000)of Division 3 ofthe �L/36-
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
F $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
A , by any applicant l'or a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4-00 1,4 of not more than five hundred dollars($500H.):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their side compensation,will do the work,and the structure Is not
intended or offered for sale(Sec. 7044, Business nod Professions DRAINS-FLOOR,ROOF,AREA,GOND. 4.00
Code:The Contractor's License Law docs 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'in
pmvo-
musts are not intended or offered for Sade.IL however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00
or improvement Is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND WN PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as 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:"rhe Contractor's License Law docs 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 contructuds)licensed pursuant to
the Contractors License Law. y SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec ,B.&P.C.for this WATER HEATER WIVENT 4.00
reason 1
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hcmby afllrm Thal I have a ctrtif emeorconscnl to self-insure' ZONING ENG.SITE NO.
or a certificate of Workers'Compensation InsuEance,or a,cerfl'ied
copy thereof(Set.3800,LabC.L % ' )f
policy No. Company JY �(ir C2* rYovx
O ❑ Certified copy is herthy famished. FIRE SPRINK ENERGY T 24
Z Z. ❑ Certified copy is filed with the city inspection division.
O Applicant MISC.- REFER TO ORD. y E] N❑ y[:] NE]
ITN CI:R'I'IFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 - FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTR. era NO. PLG. /c,G all [:] ❑ ❑ ❑
CL O f rhis scdiim need sol be comd,Cd if the pe nn it is for one TOTAL / V N V N
� Z Immi ed 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 F mit is issued,1 Shull our employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
ED Date ApplicantALTER OR ADD TO MECH, 4.00 BUILDING
} to NOTICE "10 AITLICAN'C If,after making this Certificate of Es-
coupon,
x-
coupon ,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 Shall be deemed revoked AIR HANDLING UNIT(TO 10MC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10PWC.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 for which thispermitis issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3097,Civ.C..
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that I have read this application and statethat the above VENTILATION FAN (SINGLE) 3.00
• Inl'orrnation is correct. I agree ler comply with all city and county PLUMBING f�U
ordinances and state laws rchiling to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 4/
hereby authorise representatives of this city to en ttr upon the BOILER-COMP Over 100,000BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
u (We) ugnee to save, inde..mify and keep harmless the CBy of MISC- REFER TO ORD.
Cupertino against li "' 's,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in uny way ,cane minst said City in Conseil Tence of the
gia0ti 'thisnniL / MECH.CONT. LIC. MECH.
�1
-(70- TOTAL TOTAL
tum o plicantlCuntractor K f/ Date
INSPECTOR COPY