7152 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
/ BU I LDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING y, 5 S/? -S/ K o - o APPLICATION & PERMIT
AODRE ss 7152
3(J /D j�p d BUILDING -,ELECTRICAL-PLUMBING-MECHANICAL
wry ER'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
Woos r;h z-h c•
coNTRACTOR s I
,/! -q OUTLETS-SWITCHES-RECEP 5.00/1.00
N O;Vj/-� J• GV%/�c 7n�Ic.NG. 030�J LIG HTI NG FIXTURES 5.00/1.00
)PCONTRACTORSPPLIANCES-RESIDENTIAL 4.00
_ AD OR s / �,f
O OG Oa"I "HONE 3a��s� PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6,00 PLAN CHECK FEE P.C.NO.
OR
NEER Mp
O P7 Mo QhSPh Llc.rvo. C ! SIGNS TRANS. 3.00
AR.GR ENG. PERMIT VALIDATION
f
ADDRESS / �juF�h' 7ry� CC=/ SPECIAL CIRCUIT 5.00
EMP.METER OR POLE INS. 15.00
Ar'S MOTORS SEE FEE SCH.
ADDRESS NT
SERVICE CHANGE 10.00
0 0 o LICENSED CONFRACIORS DECLARATION I O
a u. I hereby affirm that I am licensed under provisions of Clmpter 9 r ISSUANCE DATE
m c d (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
D Pt Professions Cod and t ty license is mi full foresy;tgr�efl'c'. ❑ ❑ ❑ ❑
z o In- License ss Lic.Number �o JJ ��
0 ¢ w I �- Cndmclor
H '-
. ¢ m s BUILDING PERMIT
¢•¢ w ¢
OWNER-BUILDER DECLARATION INFORMATION
A , MISC.- REFER TO ORD
.w u LL v, I hereby affirm that 1 so exempt from the inessacl Pr License VALUATION
Fu Oj Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00 6
Code:Any city or county which requires permit to construct,alter.
Q ac I Improve,demolish,Or repair any structure,prior 10 Its issuance,also ELEC.CONTR. LIC.NQ
0 ELEC.
-o¢ requires the applicant for such permit to file a signed statement that TOTAL!rj PERMIT TO
u w m u. he is licensed pursuant to the provisions of the Contractor's License
F z i Law(Chapter 9(commencing with Section 7000)of Division 30f the
¢ Ifusine.and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
4 i
¢ I- 0. the basis for the alleged exemption.Any violation o1'Section 7031.5 STORIES TYPE CONSTR.
La
dam _ by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN -WATER (EA.) 4.00
of'not more than five hundred dollars($5001.1:
❑ 1,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-
mentsarenot intended or offered for sale.If.however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improvement is 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 im-
provefor purpose ofsale.). INDUSTRIAL WASTE INTER. 20.00 RES IND CON Pa Omer
o
Cl 1,as owner of the properly.ant exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to Cnostruct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL No.
and Professions Code:1 lie Contractor'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 contmctons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ Imo exempt under See. .B.&P.C.lin thin WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSAI'ION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I Inve a certificate of consent to self-insure, ZONING
or a certificate of Workers'Compensation Insurance,or a curtifieA ENG.SITE NO.
copy thereof kS
PoNQorulmny t/
7WT • Cz•
O ❑ Certified copy isbcreby furnished.
FIRE SPRINK ENERGY T 2
Z Z � Certified y r.fldd with the iry inspection division. MISC.- REFER TO ORD.
O Applicant p /J Ae' /�a � V ❑ N❑ Y ❑ N❑
jr w CliRiu4CA�'h Uf rXI.IYTIO I¢'Ro 1 WORKERS' PERMIT ISSUANCE 6.00 FLOODZONE A.L.UG.
W > COMPENSAT'ION INSURANCE PLG.CONTE. LIC.NO. PLG.
CL O 11 Ids action need not he completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
IL I- mit is issued,I Shall not employ any person in any manner sa as to
U lie com a subject to the Workers''Compensation Lawsof California.
UJ
Dam Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} rn NO'T'ICE 'f0 APPLICANT': If,after..eking this Certificate of E
♦- ? emption,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=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATI NG UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's AddrLss
I certify that 1 have read this application and state That the above VENTILATION FAN (SINGLE) 3.00
. information is mrreet. I agree to comply with all city mol artmly PLUMBING
F,
and state laws retailing 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,costs and expenses which CONST.TAX
may 'n any ay accrue against City in consequence of the PERMIT ISSUANCE 3.00
grantingo Sperm}� // MECH.CONT. LIG NO. MECH.
'
�� �a_ q7 - TOTAL I TOTAL
native Of AXp�p�llcan�l/�Clonlraclor Dale o
INSPECTOR COPY