7276 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI G PROJECT IDENTIFICATION PERMIT NUMBER
ARCDIN oapa r,xc aM1 APPLICATION & PERMIT 7276
ooRess
,10:08II BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
�NJ7C
OWNER'S PLAN CHECK VALIDATION
NAM` OTY. ELECTRIC PERMIT FEE
CONTRACTORS
NAME UTLETS-SWITCHES-RECEP 5.00/1.00
LIC.No. LIGHTING-FIXTURES 5.00/1.00
CONTRACTOR oRs
APPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 5.00 DATE OF APPLICATION
,ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO,
OR
ENGINEER^ 'J
iflJ uc.No. SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIOATION
ADDRESS / SAN SPECIAL CIRCUIT 5.00
6tgp/ Sti rn ZIP S.as EMP.METER OR POLE INS. 15.00
ADDRESS s
AMOTORS SEE FEE SCH. J
SERVICE CHANGE 10.00
0 0 o LICENSED CONI RACfORS DECLARATION
a v u I hereby flfiOr that I am licensed under provisions of Chapter 9 ISSUANEE DATE
(cummersing With Section 7000)of Division 3 of IIIe Business and BLDG. ELECT. PLG. MECH.
rw Z Z 1'nNCssions Code,and my license is in full force and effect.. ❑ ❑ ❑
z O - License Class Lia Number
O z w Date Contractor
a y F .a B LDING PERMIT
rt w OWNER-BUILDER DECLARATION INFORMATION
Boa MISC.- REFER TO ORD
w u y I hereby affirm that I am exempt from the Contractor's License VALUATION S/FT.
F LL o j Law for the following reason.(Sea 7031.5,Business and Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to construct,alter,
re improve,demolish,or repair any structure,prior to its issuance,also FLED.CONTR. LIC.NO. ELEC.
- o u requires the applicant for such permit to file a signed statement that TOTA AZ TO
u w Cr he is licensed pursuant to the provisions of the Contractor's License
r z 5- Law(Chapter 9(commencing with Section 7000)of Division 3 ofthc
4 Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
1 o the basis for the alleged exemption.Any violation of Section 703 LS ORIES TYPE CONSTR.
ate - by any applicant fora permit subjects the applicant too civil penally ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(S500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP PES.UNITS
their wile compensation,will do the work,and the structure is not
intended or offered for sale (See. 7044. Business and Professions DRAINS-FLOOR.ROOF,AREA,COND. 4.00
Code:'fire Contractor's License Law does 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 hie own nnployees,provided that such improve
mans tare not intended or offered for sale If,however,the building GAS-EA,SYSTEM-1 INC.4 OUTLETS 4.00
nr improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving RICHhe did not build or ire REB IND CON PB Orner,
po (orpurposuofsole.). INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑ ❑
I,as owner of the property,ant exclusively contracting with
I' en ed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Low 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 contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ tum exempt under ScC. ,B.&P.C.for Ibis WATER HEATER W/VENT 4.00
"alon
Owner v Dale dMallWATER SYSTEM, 4.00 ACC.DATE Ace.FILE No,
WORKERS'(0MPENSA'rION DFCLARA1'ION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate ofconsam to selhiusure,
or u certificate of WorkersCompensation Insurance,or a certified ZONING ENG.SITE NO.
copy Ihercof(Sce,3800,Lah.C.).
Policy No, Company
O 0 Certified copy is hereby furnished. FIRE STRINK ENERGY T-24
Z2 D Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
0 Applicant Y❑ N❑ Y ❑ NO
N CERTI PICAT'li OI'EYESIPI ION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.C.
W > COMlg'NSWION INSURANCE PLG.CONTR. LIC,No. PLG.
CL 0 1'1111, rectum need not be completed if 0m permit is for one TOTAL Y❑ NO Y ❑ NO
D 2 hundred 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 1- mit is issued,I shall not employ any person in any manner so as to
U becomes bC U to the Workers Compensation Laws of California.
O w Date pplicant - � ALTER OR ADD TO MECH. 4.00 BUILDING
} w NO'I A I'.,CAN'(: If,aft r making this Certifialircre(P,SL
r 2 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.M.) 3.00
�R
CONS'I'RUC'I'ION LENDING AGENCY AIR HANDLING UNIT IOVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby aft'inn that ,here is a construction lending aguncy for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is i...ucd(Sec. MICROFILM
3097,Civ.C.). S HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name Gs ' = 0 ' ArK�Q Cr1 HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address c4 ,r •a� , o (MfT ELECTRIC
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 state laws nelaiin, to building construction, and BOILER-COW(3 H.P.or 100,000 B.T.U.) 4.00
hereby aulhoriro representatives of this city to anter 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 harnlcss the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way .'en, u•:'mt said Ry i leon.enorncc of the PERMIT ISSUANCE 3.00
gmnun+of penni MECH.CONT. LIC.NO. MECH.
G TOTAL TOTAL �!
$gna ore of Applicant/ ontractor Dale
INSPECTOR COPY