7162 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BU LOI NG PROJECT IDENTIFICATION PERMIT NUMBER
BDILOINc APPLICATION & PERMIT
ADDRESS I '\� ', ` „T/ 7162
Oslo Y N V• BUILDING —ELECTRICAL—PLUMBING —MECHANICAL
�/ OWNERS PLAN CHECK VALIDATION
J� "AME CITY. ELECTRIC PERMIT FEE
D� AN2�+ coKi°
Is.
ONE
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CONE caDRs
NAMUTLETS-SWITCHES-RECEP 5.00/1,00
TE
!/oSCo Frlerz a✓1o7LIC,No 6�271uk LIGHTING FIXTURES 5.00/1.00
A10R'S Cl RVR
ADDDRESSDRESS r"rIQ`r- J APPLIANCES-RESIDENTIAL 4.00
?_ 69 3 CoAIN(cTd v77JPHDNE 7$$- Z L PANELS 5.00 DATE OF APPLICATION
ARCHITECTSIGNS 600 PLAN CHECK FEE P.C.NO.
OR .
L , ENGINEER
LIC.NO, SIGNS TRANS. 3.00
PERMIT VALIDATION
ARCH ENG' SPECIAL CIRCUIT 5.00
ZIP TEMP. METER OR POLE INS. 15.00
APPLICANT s MOTORS SEE FEE SCH.
ADDRESS Ess
SERVICE CHANGE 10.00
woo LICENSED CONTRACTORS DECLARATION 1
AU I hereby affirm Oet 1 n 000)of ivisi provisions of Chapter 7 ISSUANCE GATE
A G m (Commencing with$eel ion]000)of Division 3 of the Itusineas and BLDG. ELECT. PLG. MECH.
H y z Professions Code,and I y Iicense a in full force and effect
z O m License Class_E'owy PeeNumber #_((1_ ❑ ❑
o_ H O Ilutc_)/..jConlructor �
a y BUILDING PERMIT
¢ w ¢
OWNER-BUILDER DECLARATION INFORMATION
oA " MISC.— REFER TO ORD
X ; u y 1 hereby collo that I am exempt from the Contractor's License
u O a Law for the following reason.(Sec 703 L5,Nosiness and Professions PERMIT ISSUANCE VALUATION 3/FT.
E m I Code:Any city or county which requiresa permit LoconstrUC1,aper, 6'00 1 /�'(J-Q
cc > 4 for to its issuances also ELEC.CONTR, LIC.NO. ELEC.—
g, �J�" `
Ix ¢ O improve,demolish,or repro,any structure,prior
- O requires the applicant for such permit In file a signed statement that TOTAL PERMIT TO
u w w he is licensed pursuant to the provisions of the Contractor's License
H z i
Law(Chaptcr9(tmnmencing with Section 7000)of Division 3 of IIIc FaQv` �/.(//(�G+L`K.(
firea Business and I'rolessions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
¢ H the basis for the alleged exemption.that
violation of Section 7m and STORIES TYPE CONSTR.
u3 � by any applicant lbr a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than live hundred dollars(S5001.):
❑ L as owner of the property.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,COND. 4.00
Cade:The C(.ntractor's Uerrisc Law docs not apply m an owner of '..
property who build,Or improves Ihercon,and who does ItIch work F IXTURES-PER TRAP 4.00 SO,FT.FLOOR AREA TOTAL ACREAGE
. himself or through his own employees,provided that such improve
mu \
enare not intended or offered for sale.If,however,the building GAS-EA.SYSTEM 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 USE
builder will have the burden of proving that he did not build or im RES INDCON PB Omer
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 20.00 ❑ E] ❑ E] EJ
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:Thon
e Contractor's I-iccnx Law docs not apply
III an owns,of property ,who build,nr improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts fur such projects with a contructorls)licensed pursuant to
the Contractor's Licenm Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. 'PARCEL NO.
❑ lam exempt under sec. ,B.&P.C.lir,this WATER HEATER W/VENT 4.00
reason
Owner - Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE N0.
WORK):RS'COM PENSA'llc)\DECLARATION WATER TREATING EQUIP. 4.00
I hereby alfim, that I have a certificate of comcnt
to c
lGinsus,
,r a cert0w.te f Workcrs'Com,tan oInsurnce.or a eerlfied r
_ZONING ENG.SITE NO.
copy eo (see3x( ,
PoSSA, AEMA IF g
O ❑ Cernied
copy Is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certil ieJ p is filed with t c ty inspection division. MISC.- REFER TO ORD. Y N Y N
nnpheCTifed.B�L�6—i r/G L ❑ ❑ ❑ ❑
CCCIiR'I'IPIC'FI--01'EXIiMI'I'I(INPROMWORKIiRS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.c.
LLI > COhIPENSATION INSCRANCE PLG.CONTR. ❑c.No. PLG.
C• O 11111, w,66n need not be completed if Ihu permit is for one TOTAL Y❑ N❑ Y ❑ N❑
Z) Z hundred dollurx(S 100)or less.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
mit is issued,I shall not employ any person in any manner so as to
LL r U become subject to the Workers'Compensation Laws of Calif _
O OL Date Applicant BUILDING
OL ALTER OR ADD TO MECH. 4.00
} rn NOTICE TO Should
become
I[Subject
making this ,s'C pPa of fix-
F Z enpision you shouldbecomesubject.o Ise Workers'Compensation APPLIANCE 4.00 PLAN CHECK A y
provisions the Labor Code., you Most forthwith comply with FEE
U such provisions
d
ns or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10p00 C.F.M.) 3.00
CONST RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE / 6�
I hereby affirm that there is a construction lending agency I'or EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,CN CJ. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name H EATI NG UN IT(OVER 100,000 B.T.U.)7.50
Lenders Address ELECTRIC
Icertifyihat l have read thisuppli,mion and state that the above VENTILATION FAN (SINGLE) 3.00
infnnnnlion Is correct. I agree In comply with all city and county PLUMBING
ordinances mW state 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 100,000 BTU)SEE FEE SCH. MECHANICAL
ubove-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep larmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.001CONST.TAX
may in an w' a,eR against said City in consequence o he
grantingo 1' Penni. MECH.CONT. LIC.NO. MECH.
101, TOTAL TOTAL
u oa4ibitntic ytractor Date
INSPECTOR COPY