7237 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
t
BUILDING PROJECT IDENTIFICATION r PERMIT NUMBER
APPLICATION & PERMIT
BUILDING 7237
- /DORE55 � r '
DING -ELECTRICAL-PLUMBING-MECHANICAL
OWNERS , PLANCHECK
NAME
ELECTRIC PERMIT FEE
PHONE
CONTR CTOWSPl
NAME UTLETS-SWITCHES-RECEP 5.00/1.00
>. I tsV)p," " nA 3 7LIGHTING FIXTURES 5.00/1.00,
CONTRACTOR PPLIANCES-RESIDENTIAL 4.00
ADDRES. I /-rG
fL/l-PJR NE PANELS 5.00 DATE OF APPLICATION
ARCH EC SIGNS 6QQ PLAN CHECK FEE P.C.NO.
OR .
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS eras. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
Zhp EMP. METER OR POLE INS. 15.00
AMOTORS SEE FEE SCH. ^
ADDDRESSDRESS g rl
SERVICE CHANGE 10.00 //�llUll
o¢i
r o o LICI:NSLD CONTRACTORS DECLARATION
Q v p I hereby:l firm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
Z w (Cau uncncin,with Section 7000)of Division 3 of the Business and BLDG. ELECT. L MECH.
Nz 1'rnfessions Code,and my license is in fall fore le t. ❑ ❑ ❑
z0 License Class ¢.Number
F a, Datc_ [L mtraL'lor
a yI-tf •�r BUILDING RMIT
¢ ¢ w¢ NPR-B LDER UECLARATIO INFORMATION
F 0t- MISC.- REFER TO ORD
w 3 ¢ w I hereby affirm that 1 am exempt from the Contractors License VALUATION $/FT.
(- .. oa Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 6.00
mCade:Any city orcounty which requiresa permit to construct,alter,
2 a, Q 2 improve,demolish,or repair any structure,prior to its issuance,also ELEG CONTR. LIC.NO. ELEC.
eu
zz - D u requires the applicant for such permit to IJe a signed statement that TOTAL P RMIT TO
K
m m he is licensed pursuant to the provisions of the Contractor's License
rz >
Law(Chapter 9(commencing with Section 7000)of Division 3 oflhe
a BI sines and 1'rofessiaos Code)or thal he is exempt therefrom and OTY. PLUMBING PERMIT FEE
S,r Oo the basis for the alleged exemption.Any violation of Section 7031.5 STO IES Tv E CONSTR.
d3�' by any applicant for a pernitsubjects the applicant on civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not amre than five hundred J,fmS(S500)J:
0 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:'rhe Contractor's License Law docs not apply to an owner of
- property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himwlf or through his own employees,provided(hat such improve-
centsarenotintendedorofferedfo,cdc.I L however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving(hal he did not build or im- . S IND CON PB Omer
Prov,for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
(3 I,as owner of the property,am exclusively contracting with ❑ C3 EI El
licensed contractors to construct (he project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Poressions Code:The C'ontmetor's 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 contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
f] I am exempt under See. ,BAP.C.for this WATER HEATER W/VENT 4.00
malars
Owner Data WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK IiRS'COMPF:NSA'I'ION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or certificate of Wor ri C e tion I so a ce.n c reified
ippy f c 38 .. I. '�
I or
p
.c 'i y L Y u Ind. FIRE SPRINK ENERGY T2
z Z ❑ Ccrti VolV.
Y is fit• wl t ci s e'ion i isi n
O Applicant - MISC.- REFER TO ORD. Y❑ N❑ y❑ N❑
m _I 'IP CA'rli OPE iM 19'ION PROM WORKIiRS' PERMIT ISSUANCE 6.00 ( FLOOD ZONE A.L.u.C.
LU � COMPIiNSAT'ION INSURANCE PLG.CONTR. LIC.NO. PLG.
O
(I In, section need d if th
not be Completed punit I
.. s for one TOTAL Y[:] N❑ Y❑ N❑
Z hundred dollars IS 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 I- mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers Compensation Laws of California.
W Dale-Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} W NOTICE 1'0 APPLICANT: IL after making this Certificate of Ex-
? eruption,you should become subject to the Workers Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEES
U such provisions or this permit shall be deemed revoked., AIR HANDLING UNIT(TO 10.000C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the perli rmance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lenders n,
Ardo HEATING UNIT(OVER 100,000 B.T.U.P.50
Lenders IsmiELECTRIC
1 certify that 1 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(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 property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of misc.- REFER TO ORD.
Cupertino against liabilities,judgments, c sls and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way me against said In consequence of the
g tingof this em MECH.CONT. LIC.NO. MECH.
AkI. TOTAL TOTAL
SiElliffe,of'App o tr clor Ua V
INSPECTOR COPY