C7270 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LD1 NO PROJECT I DENTI FICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
-Tb ' Cgac /L2- BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 7270
1 OWNER'S C'� - PLAN CHECK VALIDATION
�t NAME� ''//�� '7 QTY. ELECTRIC PERMIT FEE epry T( ���% PHONE
CONTRACTOR'S
CAME OUTLETS-SWITCHES-RECEP 5.00/1.00
LIC.No. S LIGHTING FIXTURES 5.00/1.00
co
AoOoRS PPLIANCES-RESIDENTIAL 4.00
�n/IIESS ess��'' �T''7
r�y�Y PHONE / / PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6,00 PLAN CHECK FEE P"C.NO,
OR
ENGINEER
_IC.NO. SIGNS TRANS. 3.00
ADDDRESS ENG. SPECIAL CIRCUIT S.00 PERMIT VALIDATION
z,P EMP.METER OR POLE INS. 15.00
AvvucANr's ' MOTORS SEE FEE SCH.
ADDRESS
I SERVICE CHANGE 10.00
w o O LICENSED CON"TRACTORS UECLARA'I'ION
¢OI herchy affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
ya veal (comm,ngng with Section 7000)of Division 3 a(th R sines and BLDG. ELECT. PLC. MECH.
F �' Professions CoJ and y li 7000 is in full force' J ( ❑ 1:1
❑
Z O m Licmnss:Chas Lia Number
0 r Dol, Conlmclor ^"�
a y E u BUILDING PERMIT
¢ eW/4 OWNER-BUILDER DECLARATION INFORMATION
o A ° MISC.- REFER TO ORD
X ; n m I hereby affirm that 1 am exempt from the Contractor's License ALUATION S/FT.
H .. o4 Law l'or the following reason,(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to construct,alter,
an ¢¢20 ro
impve,demolish,nr repair 1 any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC- -
0 ar requires tire r
e applicant for such peril to file a signed statement that TOTALes U. PER T T
w he is licensed pursuant to the provisions of thOe Contractor's License I.
in
Law(Chapter 9(comnnencingwitln Section 7000)ofDivision 3 ofthe
4 Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE ,L IIIEEE-
X r o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES E CONSTR.
n ; by any applicant for a peril subjects the applicant In a civil penally
of not mom than live hundred dollars($500).): ALTER-DRAIN& VENT-WATER (EA.) 4.00
❑ 1,as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 2"00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec-7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CONO. 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
memsare not intended or offered far side.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
or improvemenl is Sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or inn . NO CON PB Other
pmve for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 El ❑
❑ I,as owner of the property,am exclusively contracting with 1:1 11
license;l contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-I INC 5 V.B. 5.00 ASSESSORS PARCEL No.
anti Professions Cult: 1'he Contractor's License Law does not apply
to an owner of property who builds or improves Ihcreon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a cxntractods)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ Icon exempt un it,,Sec. ,B.&RC.for this WATER HEATER W/VENT 4,00
reus
on
owner Datc WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
W'ORkERS'COMPENSA1'ION DECLARATION WATER TREATING EQUIP. 4.00
\ I hereby affirm that I have a certificate ofcmiseN ifi
to sel Ginsure' ZONING
\ u certitleme of Workers'Compensation Ins n .or a vert ie( ENG.SITE N0.
copy I hereof l Scc.3900,Lab CA
Poli No. Company
O Certified copy is hereby furnished. •.FIRE SPRINK ENERGY T"24
Z_ Z _iETRtetLenpy is fl wish the city i etion ivision' MISC.- REFER TO ORD.
O ,pplicanYE] NE] Y ❑ NE]
FPERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.C.
W y> /CBA IF .,'I'li 'IiXfiMPDON FROM WORKERS'
W C(1 MI'IiNSATTON INSURANCIi PLG.CONTR. LIC.NO. VLG. v N Y N
CL 0 1'f his section need not be completed if the permit is for one TOTAL
::) Z hundred delta,,(S 100)or lest
U O I certify that in the performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mil is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
UJ Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING} 0 NOTICE'1'O APPLICANT. If,after making this Certificate of lis-
, � Z 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 shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.11A) 3.00 /
CONSTRUCTION LENDINGAG17NCY AIR HANDLING UNIT(OVER 10=C.EM.) 5.00 SEISMIC FEE I v/O
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance 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 HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lenders Address ELECTRIC
{ I information
Drat I have read this application ly and state that Wo above VENTILATION FAN (SINGLE) 3.00
ordinances n comet. I agree to comply with all city and county PLUMBING
ordinances and state laws relining to building construction, and BOILER-COMP(3 H.P.or 100,0008.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep ha..less the City of misc.- REFER TO ORD.
Cupertino against Rabilif udgmmnls, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
nsuy in any way acct uginst said City in conscqu, ce of the
-' ... bra I fthis permit MECH.CONT. LIC.NO. MECH.
a� TOTAL TOTAL 17
Si ppli: nntrac or ate Or
r INSPECTOR COPY