7146 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING
APPLICATION & PERMIT
ADDRESS s 714 6
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
ONNER'S PLAN CHECK VALIDATION
� ! NAMi ELECTRIC PERMIT FEE
. DN
Co r R OUTLETS
5.00/1.00
NAME
"44D LIGHTING FIXTURES- 5.00/1.00
CONIRMTOR'S I LI ANCES-RESIDENTIAL 4.00
•f aDDRE A.
P N
' ELS 5.00 DATE OF APPLICATIONonCH.7 SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENG, 00 CIRCUIT 5,OQ PEflMIT VALIDATION
ZIP rTEMP.METER OR POLE INS. 15.00 ^ /
: APPucaMOTORS SEE FEE SCH. \ ILL
Ar LICA s 4U7/V
r;.. SERVICE CHANGE 10.00
.w o'o IJCF.NSI'D CONTRACTOR511ECLARATION '
vI hereby affirm t11at I am licensed under provisions of Chapter 9 ISSUANCE DATE
to Icnmmeneing with Section 7000)of Division 3 of the Busi ss and BLDG. ELECT. PLG. MECH.
mi Professions Code,and my license is in full force' c ❑ ❑ ❑ ❑
z O m- I,ieen.0 Ivss 'c.Nwnhar
9 z F w Dow mmclnr
a y s t BUILDING PERMIT
¢.¢w a E GR DRCLARAT INFORMATION
d.0 d u MISC.- REFER TO ORD
w3 LL r I hereby affirm that 1 am exempt from the Contractor's License
do¢ Lawforthe followmgmason.(Sec.703L5,Business and Professions PERMIT ISSUANCE VALUATION S/FT.
;;- � Cade:Any city or county which na,t ires a permit to eonstmet,idle" 6.00
pto G 2 improve,demolish,or repair any struClure,prior to its issuance,also ELEC.CONTR. LIQ NO. ELEC.
0,
mauires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w2, hu is licensed pursuant to the provisions of tire Contractor's License P
_.i.Q
Law(Chapter 9(commencing with Section 7000)or Division 3 of Lire / L :s
E ec Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ 1- the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by anyapplicantforu permit sabjecfsthe applicant toacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollers($500).):
ty ❑ I,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
,tf Codc:The 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
r• himself or through his awn employees,provided that such improve-
memsarenotintendedoroffered for sale.If,however,the budding GAS-EA.SYSTEM-11 NC.4 OUTLETS 4.00
or Ropruvetocul 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 that he did not build or im-
�, prove let purpose oFort,.). - INDUSTRIAL WASTE INTER. 20-00 RES IND CON PB Omer
1] I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed retractors to construct the project(Sea 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and P,otcssions Codc:'llte Cont me fors License Law does 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 comractoris)licensed pursuant to
lire Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ l am exempt under SCC. ,B.&P.C.fortINS WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACCDATE ACC.FILE NO.
WORK ERS'COMPENSA IION DECLARATION WATER TREATING EQUIP. 4.00
I hereby a1Lno that I have a ce"ilicate of'unser)to elf-insam' ZONING ENGSITENO.
or a cc ifc' -of Workers'Col s: on so 'L, r er' icd
3
I '
O er L yf1, 'd. FIRESPRINK ENERGY TZ4
s z Z ❑ Cer h d o i.L fled it I l e 'ns cY n divis n
O APP)lzoil MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N❑f
m CP " IF'ICATE OP IiXIiMPI'ON FROM WORKERS' PERMIT ISSUANCE 6-00 a Z FLOOD ZONE \ A.L.u.C.
LU >_ CO,NPFNSA'ION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O (Phis cfion need not he completed if the permit is for one TOTAL r Y❑ N❑ Y❑ N❑
Z) z hundred dollars IS 100)or less.)
L) O 1 certify that in the performance of the work for which this per, QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL ;_ mit is issued.I shall not employ any person in any manner so as to r
U become subject to Lite Workers Compensation Laws of California.
.0 LU Dam Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
I} ED NO'T'ICE'1'O APPLICANT': If,after making this Certificate of Iix-
-.,F ? cmptiou,you should become subject to file Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor/Cude, you must forthwith comply with FEE
YY'dV such provisions or this permit shall hC deemed revoked. AIR HANDLING UNIT(TO 10,000 C.F.M.) 3.00
AIRHANDLING UNIT(OVER 10PMC.EM.) 5.00 SEISMIC FEE
CONSI'RUCI'ION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the pertornimme of the work for which this permit is issued(See HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3097,Civ.C.).
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
LendersAddress _�-
I certify that I have read thisapplication and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING-
ordinances
LUMBING-ordinances and state laws mating 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
above-mentioned properly for inspeclion purposes.
(We) agree to save, indcnmify anti keep harmless the City of MISC.- REFER TO ORD.
" s.. Cupertino against liabilities,judga ciik. costs U�Ld expenses which CONST.TAX
may in any way accrue against said Cit I I nseyuence of the PERMIT ISSUANCE 3.00
g, lg M llds It ns Af/ H.CONT. LIC.NO. MECH.
Q
TOTAL TOTAL I D.
Sii2U?F,FIApftIffanWmn1raclGr c
INSPECTOR COPY