7055 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON - PERMIT NUMBER
BUILDING APPLICATION & PERMIT 7055
ADDRESS
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNEERR�'S PLAN CHECK VALIDATION
NAME AM / 25 -4$ 3 OTY ELECTRIC PERMIT FEE
Z n G
PHONE
NAME ciORs UTLETS-SWITCHES-RECEP 5.00/1.00
NAME
Llc.rvo. LIGHTING FIXTURES 5.00/1.00
rorvTRAcroRs � APPLIANCES-RESIDENTIAL 4.00
IrODRE55 )PHpNE 2 PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6,00 PLAN CHECK FEE P.C.NO.
OR
ARCH1TNGINEER
LIE NO. SIGNS TRANS. 3.00
ADDRESS ENc. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
TIP TEMP.METER OR POLE INS. 15.00
ASMOTORS SEE FEE SCH. J\
ADDRESS
SERVICE CHANGE 10.00
o o LICENSED CUNT RACt'URS DECLARATION' • ,/�/Q
¢ o U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
yw (commencing with Section 7000)of Division 3 of the Business anti
a N BLDG. ELECT. PLG. MECH.
R w i Professions Code,and my license is in full force u it
Toy-
1-iccrosc ClasstjlS_.V'11(jCon Number yyZ�62
I w Dam-f�5/ Contractor�jypKr���- p •
a mBUILDING PERMIT
¢ ¢ a OWNCR-BUILDER DECLARA-1 ON
A ¢O u 0 - j •INFORMATION
w g LL r I hereby affirm that I am exempt !rain the Contractor's License MISC.- REFER TO ORD
FSLL o j law for the following rrcason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 6.00 VALUATION $JET.
Code:Any city or county which requires a permit to construct,alter,
-
¢ pe¢ o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR LIC.NO. ELEC. a
O¢ requires the applicant for such permit to file a signed statement that TOTAL �/S
d w m" he is licensed is to the provisions of the Contractor's License PERMIT TO
r
Law(Cha ter9(commencin ith'Seelion7000)ofDivision3ofthe S7
io Business and Professions Cute)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r- m tire fe basis for the alleged exemption.Any violation oSection 7031.5 STORIES TYPE CONSTR.
A � .- by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN& VENT-WATER (EA.( 4.00
of not more than five hundred dollars(S500).1:
❑ 1,as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 ,OCG GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered I'or sale (See 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 S0.FT,FLOOR AREA TOTAL ACREAGE
•
himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00 S �
C
improvement is sold within one year of completion,the owner- iGAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving chat he did not build or im-
DrovefarpurposeofvleJ. INDUSTRIAL WASTE INTER. 2000 RES IND CON PB Omer
.
❑ I,as owner of the property,am exclusively contracting with p ❑ ❑ p ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:'t he Contractor's Lictmw Law dues riot apply
to an owner of property who builds or improves thereon,and who LAW PRINK LMS-OVER 5(EA.) 1.00
contracts for Such projects with a concructor(s)licensed pursumv to
etc Contractor's License Law. - SEWE�-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I:un exetnot under Sc,.-,B&RC.I'nr this WATER HEATER W/VENT 4.00 U"
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACG FILE NO.
WORKS RS'COM PENSAI[ON DECLARATION WATER TREATING EQUIP. 4-00 CIV
1 hereby affirm that I have a certificate of consent to self.inxure.
or a certificate of Workers'Compensation Insurance,or a certified TONING ENG.SITE NO.
copy thereof(Sec.3800,Lah,C.)._(, A
Polity No.6i711d Company Pht�
O- ❑ Certified copy is hereby furnished FIRE SPRINK ENERGY T 24
Z Z 52 Certified copy is filed with che,city impectign division. MISC.,' REFER TO ORD. x
O APplicanL�.c / v❑ N❑ V ❑ N❑
IS rn CER'I'IPICA'I'Ii OI'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 b 07) FLOOD ZONE A.L.0 c.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. .L..�
Z (This section need not be completed if the permit is liar tone TOTAL - G/ O Y❑ NE) Y E] No
hundred Jollurs(51001 ar less.)
V O 1 certify that in the pcdonneme of me work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in any manner so us to
V become subject to the Worker'Compensation Laws of California.
O ED Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} m NOTICE '1'0 AI'I'LICAN"I: If,after..taking this Certific:ne of E.-
F Z' emotion,you should become subject bt the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such pravivons ar this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10p00CF.M.) 3.00
CONSTRUC1 ION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 5.00 SEISMIC FEE tj'U
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2-00
Hit performance of the work for which this permit is issued(Sec. MICROFILM
3097,Cia.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lenders Name HEATI NG UN IT(OV ER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that I have read this application and Stale that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING
Z • ordinances and state laws relating to building construction, and BOILER-COMP(3H.P.orl00,000&T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-CO MPI Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep hamdess the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
granting of this permit.� MECH.CONT. LIC.NO. MECH.TOTAL TOTAL /
Signature u,ff A,mIi,!u Contractor a
,.INSPECTOR COPY