7016 (3) APPLICANT TO FILL IN dFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFI CATION PERMIT NUMBER
eUILDING APPLICATION & PERMIT
ADDRESS
/ / BUILDING —ELECTRICAL—PLUMBING—MECHANICAL 7016 1 6
OWNER'S PLAN CHECK VALIDATION
NAME / LQTY. ELECTRIC PERMIT FEE
1� e.� a PHONE LJ51
CONTRACTORS C20'\
NOUTLETS-SWITCHES-RECEP 5.00/1.00
AMf /
f /n 11C.No. gLOJx+eIC IO LIGHTING FIXTURES 5.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADDRESS s0/ 10 Py
C 1 O PHON PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS
6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
' uc.No, SIGNS TRANS. 3.00
ADDRRESS ENG, - SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
zIP rFEMP.METER OR POLE INS. 15.00
APPLICANT'S MOTORS SEE FEE SCH. ///f
ADDRESS [�
SERVICE CHANGE 10.00 /` r//4S
a.g, LICENSED CON'I'RACI'ORS DECLARATION U
a o E~a I hereby affirm that 1 ani licensed under provisions of Chapter 9 ISSUANCE DATE
m<H (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. M CH
H w z Prul'essionx Code,unit my license is in full Ibrec and effect
z O m— License Class I Lic.Number
Q z n..w Lane Contractor
a m I BUILDING PERMI
¢ ¢w a OWNI:R-BUILDER DECLARATION INFORMATION
0 MISC.— REFER TO ORD
X. 3 u r I hereby affirm that I am exempt trrm the Contractors License VALUATION yIFT.
H u O a Law for the lullowingreaslm.(Sea 703 1.5,Business and Professions PERMIT ISSUANCE 6.00
Code:Any city or county whidh requiresa permit toconxlmct alley,
¢ ¢Q O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. -
0¢ requires the applicant for such permit to file a signed statement that TOTAL PERMI
A w m he is licensed pursuant til the provisions of the Contractor's License _
r z i
Law(Chapter 9(Commencing with Section 7000)of Division 3 of to MCL T
a Business.,,it Professions Code)or that he is exempt therefrom and GTV. PLUMBING PERMIT FEE
¢ m the basis for the alleged exemptimi rAny violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects lire applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
four mom than five hundred dollars($500),):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 DCC.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,AR EA,GOND. 4.00
Code:The Contractor's License Law does not apply to an owner of
prlPerty who builds or improves Ihenon,and who docs such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or thrimp his own employees,provided Iliat such improves
lents are mol ir(ended or offered for sale.If.however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 4.00
•- or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 (EA.) 100 BUILDING USE
builder will have tire burden of proving that he did not build or im- . . .
RES IND CON PB Omer
Cl 1,
for purpose of sale,). x. - INDUSTRIAL WASTE INTER. 20.00 El El ❑ - El EJ1,us owner of the properly,am eselusively'cantmaing with
licensed contractors 10 construct the project 1 . 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's LicensE Law does not apply
to in owner of property who builds 0,unpr0
vcs thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with11 cnntractu(S)licensed pursuant to
the Contractor's Lic ense Law. SEWER-SANITARY-STORM EA.200ft/8.00 ,d T O. PARCEL NO.
❑ l am exempt under Sec.—,B.&P.C.for this WATER HEATER W/VENT 4.00 -
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affrnn that I have u certifilm,of consent In self-insure' ZONING ENG.SITE NO.
or a'cYrtificute of Workers Conoco.Goo Insurance,or a certified
copythara "(( is
Policy N, t _
O ❑ Coifed copy is he by lumishcd. FIRE SPRINK ENERGY T 24
z Z Culificd ly mcJ with t tt it�y� ti�th�div'sioa MISC.- REFER TO ORD.
In .PERMIT ISSUANCE 6.00 FL000 zoNE A.L.u.c.
� ] C. FICCOM P COMPENSATION
ION FROM W'ORKIiR
W COMPIiNSA1'IUN INSURANCIi PLG.CONTR. LIC.NO. PLG. Y❑ N❑ Y ❑ N❑
Z ('Phis section need not be completed if the permit is for one TOTAL
hundred dollars(S 1001 or Icss.l
U O 1 certily that in the performance of the work for which this per, GTV. MECHANICAL PERMIT 9 FEE . FEE SUMMARY
W F mit is issued,I shall not emp1oy my beton m any manner m as t0
U become subject to the V is'Compensation Laws of California.
0- Dam Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} In NO"IACle'10 AITIACAN'1: if,after making this Cruilieme 01
Fs-eruption,you should become subject to the Workers'Compensation APPLIANCE4,D0 PLAN CHECK
previsions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit Shull be deemed revoked. AIR HANDLING UNIT(TO 10,000G .M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 5.00 SEISMIC FEE
• I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
tat jxrformmn" of the work for which this permit is issued(Sec. MICROFILM
3097,Gv.0,). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lenders Address ELECTRIC
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
informalion is correct.1 agree to comply with all city and county PLUMBING
ordinan«.a and state laws relining 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 100,0008TU)SEE FEESCH. MECHANICAL 70
•• above pientioned properly for inspection purposes.
(We) agree to save, indemnil"y and keep harnhe. the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in tiny way accrue against said City in consequence of the
granting this permit MECH.CONT'. LIC.NO. MECH.
t 4 TOTAL -7 TOTAL /
si, a m til' pct caul Gmtrator Dago
INSPECTOR COPY