C7226 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS DR-
/O� BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 7226
OWNER'$ \,PeAN CHECK VALIDATION
NAME TY. ELECTRIC PERMIT FEE
tS504.1Q�F ,„ONE �`�3�
NomERacTons UTLETS-SWITCHES-RECEP 5.00/1.00 SII
UGRIC LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S G T APPLIANCES-RESIDENTIAL 4.00
ADDRESS
s,51 A)T015iC 957/6 PHONE a7901a PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO SIGNS TRANS. 3.00
Boo Ess ENG SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
. ZIP EMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
Hoo LICENSIED CONTRACTORS UBCLARATION
¢o U ,1 hereby affiml that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
F - 000)of Division J f the H siness and '
k i` k IDI w g`w barn]'arse iBTn%full fitrcg nJ.e(fi.el If i BLDG. ELECT PLG. MECH.
o Prof scions Cod' -n 'lice tVOf aF _ _
z o m I I Carse Clan LicNumher yEl.
0 - o Dutc Cantruet.r-A�Y�� :� ��� ;p.n
I
¢ m ¢ a OWNER-BUILDER DECLARATION BUILDING PERMIT INFORMATION
a. raMISC.- REFER TO ORD
3 U. H hereby uffum that I am exempt from the Contractor's License VALUATION $/FT-
H ..
O< Law for the following Peas...(Sec.7031.5.Business and Professions PERMIT ISSUANCE 6.00
Code:Any cityorcounty which requires a permit to construct,alter,
¢ ¢ QUO improv,,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w mhe is licensed pursuant to the provisions of the Contractor's License -
rzi
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE III tC
¢ D
¢ r$ the basis for the allcRcd exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
Aw byany applicant fora permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(8500).):
❑ 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
Code: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 SG FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
Rents are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-111NC.40UTLETS 4.00
or improvement P 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 iR- RES IND CON PR Odor
prove for pawner of rale.). - INDUSTRIAL WASTE INTER. 20.00
❑ Las owner of the property,am exclusively contracting with El El El El El
contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5V.8. 5.00 ASSESSORS PARCEL NO.
and Professions Code..l'he Contractor's License Law does not apply
to an owner of properly 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 Commcmr's License Law. SEWER-SANITARY-STORM EA.200ft/5.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. .H.&P.C.for Otis 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
1 hereby affirm that I hove u certificatr of consent to self-insure. ZONING ENG.SITE NO.
or u certificate of Workers'Compensation Insurance,,or a certil'ieJ
copy thereof .3 3ggo0pbab.CJ.
P.Imy .No.(dL(L1@ConlPdtiy F,L176 J l9S 1F "" 1
Q ❑ �crlitiedc}'P1�Is hereby turn-shed
. ' FIRE SPRINK ENERGY L24
z Z C.-Clc fled('opS�Y'(Ileo ve D t Inspection division.
O Applicant'g 1J' n11�I MISC.- REFER TO ORD. Y ❑ N❑ Y N❑
jr Lo CERT'IFICA'1'1;OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOODZONE A.L.u.c.
LU > COMPIMAT'ION INSURANCE PLG.CONTR. LIC.NO, PLG.
O ('this section need our be completed if the permit is for oI e TOTAL Y❑ N❑ Y[:] N❑
Z hundred dollam($100)or less.)
U O I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mit is issued, I shall not employ any person in any manner so as to
Q become subjecl to the Workers'Compensation Laws of California.
Do Date Applicant ALTER OR ADD TO MECH. q,OB BUILDING
} m N(I'1'ICE*1'0 APPLICANT;If after making this Certificate of Ex-
� Z citsption,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=CF.M,) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 5.00 SEISMIC FEE
I hereby aflinn But 01ere is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work Parr which this permit is issued(Sec. HEATING UNIT IT 100,000 B.T.U.) 4.00 MICROFILM
3097,Civ.C.).
Lender's Name
Lenders Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 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 relating to building construction, and BOILER-COMP 13 H.P.or 100,000 B.T.U.) 4.00
hereby authorizn representatives of this city to enter upon the BOILER-COMP(owr 100.000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MUSIC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which --- peCONST.TAX
may n^any way Decor, against said City in Consequence of the PERMIT ISSUANCE ' 3.00
gran mg o tape rm x MECH.CONT. LIC.N9 MECH.
(� + p�/J_I� �//� / ,y// I TOTAL Q TOTAL �DO
Signature if Applmaot)Contr et.r Date /P r ��c�T��y �.Y�lr
.INSPECTOR COPY