7037 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
AUwODNREERs' Z L/tjJ� BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
7037
S
PLAN CHECK VALIDATION/
• Y� /, /'\ Uk v-s� OTV. ELECTRIC PERMIT FEE 3� �` /L. O / '7�//
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I/�/V
PHONE
CONTRACTORS _ UTLETS-SWITCHES-RECEP 5.00/1.00
N '
A' us..No. LIGHTING FIXTURES 5.00/1.00
coNTRAcroq'S
APPLIANCES-RESIDENTIAL 4.00
Es - t
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEEII
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENO' SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
zIv EMP.METER OR POLE INS. 15.00 ^
APPLICANT'S MOTORS SEE FEE SCH. \/(/f\'(-,(./
ADDRESS
SERVICE CHANGE 10.00 /- ,
��
o o LICENSED CONTRACTORS DECLARATION
G u U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
H G N (commencing wiDIS ]0003 othe 1uean•••••• DBLDG. ELECT. PLG.- MECH.
H 12 z I'Hsfine Ch Col r �ccnze is in full I'or / ❑ ❑ ❑ ❑
z O y- License Class Lic.Numb t l..
Q F w Dale_ _ Contract
a Y ¢ OwNli k-BU hDIiR uBCl.n A'I'ION +:• BUILDING PERMIT
E a a" MISC.- REFER TO OR INFORMATION
wS LL,r 1 hereby affirm that I am exempt from the Contractor's License VALUATION
Lou_o j+ Law Grr the following mason.(Sec.7031.5.Nosiness and Professions PERMIT ISSUANCE 6.00 (J
f vsYf Code.Any city or county which rquiresa permit to construct,alter, ELEC.CONTR. LIC.NO.
O iFoloove,demolish,or repair any structure,prior to its issuance,also ELEC.
PLL requires the applicant for such permit t0 file a signed statement that TOTAL PERMIT
a w m he is licensed pursuanl to the provisions of the Contractor's License r\-y T'p`
F z i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe •-vo LA•02-- J S'�C-�
e tlusirss and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
M k o the basis for the alleged exemption.Any violation of5eetion 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant o a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
TO not mora than five hundred LmdhO(5500).):
❑ I,as owner of the property,or my anpsloyecs with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.Uw/
their sola conlpensalion,will do the work,and the structure is not
intended or offered for safe (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 SO.FT.FLOOR AREA TOTAVACREAGE
. hmimself or through his own employees,provided that such improve-
- mvs ore nut intcndcd'or offered for safe.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
or impruvcrnt nt is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Omer
Olt I prove for purpose ofwlc.). - INDUSTRIAL WASTE INTER. 20.00
C] 1,In uwncr nl'the praperty,um exclusively contracting with - ❑ ❑ ❑ ❑ ❑
licensed conlraetois Io construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and 1'rofessians Code:'I'he Cm-amclnr's License Law docs 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 x conlracions)beciu d pursuant to
¢ the Contracwr's License Law.
I
SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ um exempt under Sc,.-,Sec. tl,&ItC.for This WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ,e�' ACC.DATE ACC.FILE NO.
` WORKERS'(0MPIiNSA'IION DECLARATION WATER TREATING EQUIP. 4.00.�`z,G i-
I hereby affirm that I have a certificate of emosenl la self-insure, ` ZONING ENG.SITE N0,
or a ceri t:cmc fff W C I nation II ence,or a certified
Copy Ihl'r eI�/a
p"Ific (. III y -
O D 'Ritiede is hereby famished. .a 1 FIRE SPRINK ENERGY T 24
z ❑ Certilied_-opy ' tl with amrztiondivisioo. MISC.- REFER TO ORD.
0 Applicant ' - c J - Y ❑ N❑ Y ❑ N❑
CC = CER I'IFICA'I'E O Is I\XIM119'ION I'ROM WORKERS' PERMIT ISSUANCE 6.00 FLOOOZONE A.L.U.C.
LU �_ COMPIiNSATION INSURANCE PLG.CONTR. LIC NO. PLG.
CL 0 (*'his section need net be completed if the permit is for one TOTAL I Y❑ N❑ Y ❑ No
Z) Z handred doILD,IS 100) it less.)
L) 0 1 certify that in (lie performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mit is issued,1 shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
0 W U:da Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} re. NO'I'I CE'10 APPLICANT: If,after making this Cerlilice a of Es
F Z tanption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
U provisions of the Labor Code, you must forthwith comply with FEE
such provisions or this permit shall be demnud revoked, AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION L17NDING AGENCY AIR HANDLING UNIT(OVER 10=11C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
(lie
peMICROFILM
Cvrmance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.P.50 ELECTRIC
Lander:Address
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
infonnatim, is correct. I agree m comply with all city and county PLUMBING
ordinances and state laws relating to building conrtruuton, and 1301 LER-COMP(3 H.P.or100,000B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Ova,100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly 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
m' 'n any way accrue against BI 'ty i consequenle=e of the PERMIT ISSUANCE 3.00 y`
grunting his permit. ECH.CONT. LIC.NO, MECH.
TOTAL TOTAL GSA
Signature ul"_ pliant Contract r Date
INSPECTOR COPY