7072 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATION PERMIT NUMBER
BUILDING c I I APPLICATION & PERMIT/DURESS Ur 7U7Z
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
O pq 19 PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
n NCS0 41
CONT Ac Rs
NAME OUTLETS-SWITCHES-RECEP 5.00/1.00
LIC.NO, LIGHTING FIXTURES 5.00/1.00
CONTRACTORS
ESS APPLIANCES-APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
NGINEER
♦,/le
LIC.NO. bO SIGNS TRANS. 3.00
ADDRESS ENG' SPECIAL CIRCUIT - 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00 /f
APPLICANT'$/ � r. /„ ]9_Y /
ADDRESS .J /y MOTORS SEE FEE SCH.
t- VqL S 7 SERVICE CHANGE 10.00
0 0 o LICENSED CONTRACTORS DECLARATION
¢ it U 1 hereby affirm Hurl 1 rm licensed under provisions of Cluipte,9 ISSUANCE DATE
Ha N (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H m z Professions Code,and my license is in full force and effect. EJ ❑ El Z o H - L cense Class Lic.Number ,
C) Date Contractor
a Y BUILDING PERMIT
¢ ¢w¢ OWNER-BUILDER DECLARATION INFORMATION
w3 I hereby MISC.- REFER TO ORD III
LL m ereby affirm that I um exempt from (he Contractor's Licence VALUATION $/FT.
F a_
o j Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 6.00 -�
Code:Any city or county which requinsu Penult tocuns(rml,alter,
2 ¢ ¢ 2 improve,demolish,or repair.ary structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
DLL requires the applicant for such-permit t)file a signed statement that TOTAL d•/ _ PERMIT TO
L, m i he is licensed pursupnl lu the prove ns of(be Contractor's License
r z
Law(Chapter 9(commenci: with Se yon7000)of Division3ol'Hhe
a Business and Professions Code/or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE 7
R I Do the basis for the alleged exemp lion.Any viiSla(ion of Section 7031.5 STORIES TYPE CONSTR.
ate _ by any applicant for a Permit subjects the applicant to a civil penalty gLTER-DRAIN&VENT-WATER (EA.) 4.00
-
of not nnorc than five hundred dollars 155001.1:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
I their sole compensation,will do the work,and the structure Is not
intended cur offered for sale IS,, 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Code:The Comraclor's License Law does not apply In an awncrof
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""P....v.
.inerts are not intended or offered for sale.11,however,the budding GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING US
builder will have life burden of,proving that he did not build or im- RES IND CON PB Umat
P r v•for purpose ol'salc.l. -� INDUSTRIAL WASTE INTER. 20.00
�. 1,as owner of the properly,am exclusively contorting with - ❑ ❑ ❑ ❑ ❑
lic�ed contractors to con,truct'thc 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 riot apply
to an owner of property will builds or improves thereon,arid who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a comtructorio licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA. 200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt Imder Se ,BAP.C.for(his WATER HEATER W/VENT 4,00
reason
OW1 ate WATER SYSTEM 4.00 ACC.DATE.. -ACC
,FI NO.
WORK ERS'COAIPENSA7lON DECLARATION WATER TREATING EQUIP. 4.00
1 hereby at that I have it certificate of consent to cell-insure, ZONING ENG.SITE NO.
or a Certificate of Workers'Compassudon Insurance,or a Certil led
copy thereof(Sec.3800.Lab.C.).
Policy No. Company _
O ❑ Certified copy is hereby famished. FIRE SPRINK ENERGY T 24
Z ❑ Certified copy is filed with [tic city inspection Division.
0 Applicant MISC.- REFER TO ORD. YE] N❑ Y ❑ N[:]
0: CISR'TIPICATE OF FXHMPTION PROM WORRIERS' PERMIT ISSUANCE 6.00 FLOODZONE A.L.UC.
W > COWHTNSAT10N INSURANCE PLG.CONTR. LIC.NO. PLG.
Z (This section need not be completed if(he permit is for one TOTAL Y❑ NE] Y❑ NE)
hundred dollars(S 1001 or test.)
U 0 1 certify 06t in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any person in any nattier so as to
U become subject to the Workers'Compensation Laws of Calilurnia.
a Dam Appli°antALTER OR ADD TO MECH. 4.00 BUILDING
} W NO1'ICI'TO APPLICANT: If,after making this CrHifnemc Of Ex-
F 2 emption,you should become subject to the Worker'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCr10N LENDING AG17NCY AIRHANDLING UNIT(OVER 10,00DGEM.) 5.00 SEISMIC FEE '
I hereby affirm that (here 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.l. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address H EATI NG U N IT(OVER 100,000 13.T.U.)7.50
ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00 .11
information is correct. 1 agree to comply with all city and county PLUMBING
ordinances and late laws relating to building construction, and BOILER-CDMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over t00,000BTU)SEE FEESCH. MECHANICAL
abovemuntioncd property Inn inspection pu its..
(We) agree to save, indemnify and keep harmless the City of MISC.- - REFER TO ORD.
Cupertino against liabilities, c .is:cul expenses which PERMIT ISSUANCE 3.00CONST.TAX
ay in any wuY nccrl• n consul •n, o'the
fit.nyo is peon" MECH.CONT. LIG NO. - MECH.
G TOTAL TOTAL
g e of pHi an r c )ate
INSPECTOR COPY