7071 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
AD0-y / APPLICATION & PERMIT 7 71
ADDRESS RE55 r I
QBUILDING-ELECTRICAL-PLUMBING-MECHANICAL
O ry 5 PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
PHON
co RAcrons
NAME UTLEL-SWITCHES-RECEP 5.00/1.00
LIC.NO. LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S APPLIANCES
PHONE
4.00
ADDRESS
PHONE PANELS 5-00 DATE OF APPLICATION
ARCHITECT SIGNS 6,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIc.No. SIGNS TRANS. 3.00
ADDRESS ENPERMIT
CIRCUIT 5.OQ PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
P4 L
V �J
ADDRESS (�� S, y [/
t; see L p 7 SERVICE CHANGE 10.00
Ore .
�o o LICENSED CONTRACTORS DECLARATION
Er. 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
m <w . ELECT.(commencing with Section 7000)of Division 3 of the Business and BLDGPLG. MECH.
r N i Professions Code,and my license is in full force and effect. ❑ ❑ ❑ ❑
z 0 m - License Class Lia.Number
o z H w Dale Contractor .
Y E BUILDING.PERMIT
K a w< ,OWNER-BUILDER DLCLARA I ION INFORMATION
AOAD MISC.- REFER TO ORD
q w 3 a r 1 hereby affirm that I am exempt from the Contractor's License VALUATION
-F u.0 J Law for the following reason (Sec 7031 5,Business and Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to Construct,alter,
IS u, Q improve,demolish,or repair any structure,prior to Its Issuance,also ELEC.CONTR. LIC.NO. ELEC.
O¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
a w m LL he is licensed pursuant to the provisions of the Contractors License
r t
Law(Chapter 9(commencing with Section 7000)of Division 3 oflhe W
< Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE �G ZL-7 �• �Lt�'
¢ r Do the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
aim by any applicant for a Permit Subjects the applicant to a Civil penalty gLTER-DRAIN -WATER (EA.) 400
of not more than rive hundred dollars(1500).1:
❑ I,as owner of the property,of my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the slructum is not
intended or offend for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Cod,CodThe Contractor's License Law don not apply to an owner of
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 4.00 SEE FT.FLOOR AREA TOTAL ACREAGE
. himself or through his own employees,provided that such Improve-
meals are not intended(it offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
or improvement is said within one year of completion,the owner GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
huildcr,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 ❑ IN ❑
as owner of Ile property,am exclusively contracting with
tcontractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5-00 ASSESSORS PARCEL NO.
and Professions Code I'he C'ontractor's License Law does not apply
to an owner of property who builds or improves thereon,and whoLAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contraclons)licensed pursuant to
the Contractors License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCELNO.
❑ lain exempt under Sec.-,BAP.C.for this WATER HEATER W/VENT 4.00
reason
( Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO,
WORK FRS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING
or a certificate of Worker'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof(Sec.3800,LaDCJ.
Policy No. C..mpamy
0 ❑ Certified copy is hereby furnished I FIRE SPRINK ENERGY T2
Z Z ❑ Certified copy is filed with lire city inspection division. MISC.- REFER TO ORD.
Q Applicant Y ❑ No Y ❑ N❑
c W CIi RI'1171CAfl;OIs IIXIiMP7TON FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.UF.
L COMPENSATION INSURANCE PLG.CONTR. LIC.No. PLG. Y N� v N�
. CL Z ('Phis section need not be completed if the permit is for one TOTAL
hundred dollars IS 100)or ICs.)
U O 1 certify that in the performance of Bra work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued I shall not employ any person in any manner w as to
become subject to the Workers Compensation laws of California a
O w Dale As lienor BUILDING-
a 1 p ALTER OR ADD TO MECH. 4.00
} w N01'ICE TO APPLICAN"f: If,after making(his Certificate of Ex.-
F_ 2 emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you mast forthwith comply with FEE
U such provisions or this permit shall be decared revoked AIR HANDLING UNIT(TO 10,000CF,M.) 3.00
CONST RU CON L17NDING AGENCY AIR HANDLING UNIT(OVER 10D00C.EM.) 5.00 SEISMIC FEE
I hereby afftnm that (here is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this Demur is issued(Sec. MICROFILM
3097,CN.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT IDV ER 100,000 B.T.U.)7.50
Lender's Add.ns ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
• inlbnnation is arrrect. I agree to comply with all city and county PLUMBING
ordinances and slam 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 enter upon the BOILER-COMP(Over lW,OOO BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree (o save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, cost and expenses which CONST.TAX
i may in any way accrue again t seri ity n conseque ee of the PERMIT ISSUANCE 3.00
R��r'X"r
tiperm(. Y ECH.CONT. LIC.NO. MECH.
/ /y TOTAL TOTAL
plicant/ ontlacor D to
INSPECTOR COPY