7166 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
3
BUILDING PROJECT I DENTI FICATION PERMIT NUMBER
rDnLOnNG APPLICATION & PERMIT �� ��
ADDR -�Ess 'f
W"� lMP�U �(� BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
I OwNER's' PLAN CHECK VALIDATION
•L'�f�ntull�x
QTY. ELECTRIC PERMIT FEE
,GJ'TJ IL PHONE
7- CONTRACTORS
V' OUTLETS-SWITCHES-RECEP 5.00/1.00
N �3
2P 23(rEeMT U LLIGHTING FIXTURES 5.00/1.00
T
CONTRACTOR 5 MT
APPLIANCES-RESIDENTIAL 4.00
v wa�PANELS'hhkI`(- � (0I�^
5.00 DATE OF APPLICATION
- ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO,
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.
oo Ess ENG, SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00 (`
APPLICANTS MOTORS SEE FEE SCH. J
ADDRESS
SERVICE CHANGE 10.00
,00 LICIiNSIiU CON'T'RACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE:
m<m (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
0 N z 1'..."l,cu s Cod a license ism full for (f
2 o m- License Class Cml Number
-
0 ❑ ❑ ❑ ❑
g zF'wo UatcA ✓,G a^Contranor_.^t d/_.+..�
Ic Y f P'IC/ 3 �f.•N L"l�� d BUILDING PERMIT'
¢ ¢w¢ OWNIi R-GUILDER UECLARA'I'ION t INFORMATION
n: a3: , MI$C.- REFER TO ORD
w S LL r I hereby collo that 1 so exempt from the Contractor's License VALUATION $/FT.
F LL m j Law for the following reason.(Sec 7031.5.Business and Professions PERMIT ISSUANCE 6.00
Code:Any city or county which retuiresa permit to construct,alter, OO
re u Q improve,demolish,l,r repair any Structure,prior to its issuance,also ELEC.CONTH. LIC.NO. ELEC. �U/ O
D¢ myuims the applicant for such permit to file a signed statement that TOTAL PERMIT TO
¢ w as" he is licensed ppursuant to the provisions of the Contractors License
Fzi Law lChapter 9lcommencingithSection 7000)ofDivision 3of(lie ii 'C'L'/d./c v'vdG; Tq
4 Businessand Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
F s Do STORIES TYPE CONSTR.
¢ I- the naris for the vllegeJ exemption.Any violation of Section 7031.5
aim by any applicant for a permit subjects the applicanLto a Civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
,)four n mm than five hundred doll..(5500).):
\❑ I,as owner of the property.or illy employees with wages as BACK FLOW PROTECT. DEV ICE 2.00 DCC.GROUP RES.UNITS
Ih�iu sole c0m pemettinn,will do the work,vEd 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 docs 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 TOTAL ACREAGE
himself or through his own employees,provided that such intprovc-
mendsamnotintendedoroffered for Sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is ttdd within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
-i builder will have the burden of proving that he did not build or im-
f p rove for propose of Sade.). INDUSTRIAL WASTE INTER2000 RES IND CON PB Omer
J ❑ I,as owner of the property,am exclusively contracting with . .
❑ ❑ ❑ ❑ ❑
f licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
r, and Professions Codc:'The Contractor i'License Law does not apply
to an owner of property who builds or improves thereon.and will, LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts for such projects with a'contmetol(sl licensed pursuant Io
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
�• ❑ 6 am exempt under Sec. ,G.&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner Uate WATER SYSTEM 4.00 ACC.OATE ACC.FILE NO.
WORKERSCOMPFNSMION DECLARATION WATER TREATING EQUIP. 4.00
I hcrcby:Ufirm that 1 have a certificate of consent to self-insure. ZONING
or a certificate of Workers'Compensation
insurance,or a certified ENG.SITE N0.
U hereby
❑ CeU� cd copy is hcrcby famished. FIRE SPRINK ENERGY T-14
Z Z ❑ Cut, d copy /f edwith the ity inspection division. MISC.- REFER TO ORD.
Q Applican e fri HIT., �� Y ❑ N❑ Y ❑ N❑
M y CER1'IFICA'I'1:OI'Ii XEMPI(ON FROM WORKI!RS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.Lu U.C.
111 >_ COMPIiNSA'f1ON INSURANCE PLG.CONTE. LIC.NO. PLG.
d O (This section need not be Complete(] if the permit is for one TOTAL Y❑ NE] Y❑ N❑
Z hundred dollars($100)or li,10
U O I certify that in the performance of the work foo which this per- QTY. 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. c
O w BUILDING t7 v SL
O_ Dat° Apn1i°Pot ALTER OR ADD TO MECH. 4.00 1
} W NOl'ICF TO APPLICAN'1: If,after making this Certificate of lex-
., Z eruption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions.of the Labor Code, you most lo0lovith comply with
U sucll Provisions or this permit shall be derailed revoked. AIR HANDLING UNIT(TO 10p00C.F.M.) 3.00 FEE
CONS'T'RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
firm re / V
1 Imreby afthat theis a construction lending agency far EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sue. MICROFILM
7097,Cw.CJ. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lenders Adders HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
FAN SINGLE 3.00
I certify Clad have read thisapplication
coumion and sl,@ that doeaboveounty VENTILATION ( 1
information n estate l I agree fi cool Ply with all city and c, and PLUMBING
ordinances and stain lows relating a huilding construction, and BOILER-COMP(3 H.P.Or 100,006 B.T.U.) 4.00
hereby authorize representatives of this city to ender,upon the BOI LER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree m save, indemnify and keep harmless tide City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
ase in any way accrue against said City a ace of the PERMIT ISSUANCE 3.00
gu I of is 1J�rnl . � MECH.CONT. LIC.NO. MECH.
/ Y c `I S TOTAL TOTAL t
( Signature of Applicant/Contractor Wtc
INSPECTOR COPY