7033 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIF I CATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 7033
i ADDRESS _ BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
o L 9 'V
/ CoNER'S PLAN CHECK VALIDATION
+ l "AMOTY. ELECTRIC PERMIT FEE
co rRAcroas UTLETS-SWITCHES-RECEP 5.00/1.00
�.,.� NAM[ ,AI rr J'
Pad C IG uc.No. Z f LIGHTING FIXTURES 5.00/1.00
TRACTORS PPLIANCES-RESIDENTIAL 4.00
` ADDREss
PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER 90VjDl 01f A$,FKL(C.No SIGNS TRANS. 3.00
ADDRESS ENG.
SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
' zIP EMP.METER OR POLE INS. 15.00 /
APPLICANT'S MOTORS -
ADDRESS SEE FEE SCH. S
SERVICE CHANGE 10.00 ��f/S
wo o LICENSED CONTRACTORS DECLARATION
rt u o 1 helchy affirm (),at I am licensed under provisions of Chapter 9 ISSUANCE DATE
haw (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
0 N z 14ofrssiom Code and my license is in full fo rmeafield'/ � ❑ ❑ ❑ ❑
.i o g- License Clas Lic.\umber 1
o H Datr1`Lj Contractor
x E IBUILDING PERMIT
tc w a OWNER-BUILDER DECLARATION INFORMATION
oA ° MISC.- REFER TO ORD
w 3 r .1 hereby affirm that 1 am exempt from the Contractor:License yy VALUATION S/FT.
HLLo J Law for the hollowing reason.(Sec.7031.5,Business and Profession, PERMIT ISSUANCE 6.00 d 1
Code:Any city or countyswhich requires a permit to construct,alter,
ce ¢ 0 improve,demolish,or repair any structure,prior to its issuance.also ELEC.CONT. L LIC.N0. ELEC. w �
y rcglrires the applicant for such permit to the a Signed statement that TOTAL PERMIT TO
m LL
n w he is licensed pursuant to the provisions of the Contractors License
Hie
Law(Chapter 9(commencing with Section 70004ofElivision 3 ofthe '7i UPJ
< B&uiness and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
D the hasis N,thcallred excmlion.An violation of Suclion 7031.5 STORIES TYPE CONSTR.
o g P y v'o.
by any upplicum faupennit subjects the applicam touvisit penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars($500).):
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 compenmlion,will do the work,and the structure is not
emended or offered for sale ISec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:'rhe Contractor's License Law does no(apply to un uwnerof
properly who builds or improves thriven,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 improve-
nlen6are not intended oroffered for sale.If.however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 4.00
ar improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have fit,burden of proving trial be did not build or ire- RES IND CON PB Omer
prove I'or purpose of stile). INDUSTRIAL WASTE INTER. 20.00
0 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to ter owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
conlraels fursuch projects with a contraclous)licensed pursuant to
the Contranur's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
Cl Tum ezenlpt under Sec. .B.&I'.C.for this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO,
WORKH RS'COMPF NSA'fION DGCLARA'I ION? WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of cr n alit h tall-insure. Ill �' ZONING
X or a cerlificate of Worker;Compensation Insurance,ot,aertifie� ENG.SITE NO.
/ copy thereof(Sec.3800,Lrb C.1. / If l
Policy No. Company �p rL'L.t v�`I /'O `•
O 0 Certified copy is hereby furnish eY. FIRE SPRINK ENERGY T-24
zCcrlific py s fled�Ilh III inspeclion division. MISC.- REFER TO ORD. v❑ No , Y ❑ N
p 0 ApplicanL �f- /�[f�
F'- y PERMIT ISSUANCE 6.00 � r.� FLOOD ZONE A.L.U.C.
Lu - fs1i R'I'I PICCOMPE lir fION IFROM WORKERS'
W COM hot he I completed
INSURANCE PLG.CONTR. LIC.NO. PLG. / d1. Y❑ N❑ Y❑ N❑
Z
(I his dollar, Aced not he crompleled if the permit is for one TOTAL G - -
hundmA dollars IS 100)or less.)
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
W 1- mit is issued,I shall not employ any person in any manner so as to
O W hee... suhjact the Workvrs'C pen lion brnia. '
Uwe_ nnpucom - 4 A .«m G"< BUILDING �,l S-0
��; / ALTER OR ADD TO MECH. 4.00 �f
} tail NOT'ICIi 'f0 PI'1.CAN'T: If,a ler making this Certificate of Ex
F Z nmption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
pruvi'muS of the labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 3.00
CONST'RUCIION LENDING AGENCY AIR HANDLING UNIT(OVER 10)M0QFM.) 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.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATINGUNIT ER 100,000 B.T.U.)7.50
Lender;Address (OVELECTRIC
1 certify that I have read this application and state that rho above VENTILATION FAN (SINGLE) 3.00 O-L
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 �u
hereby authorirc representatives of this city to enter upon the BOILER-COMP Ov.,100,ttooBTU)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 UR CONST.TAX
may in any way accrue against said City in conse nonce f the PERMIT ISSUANCE 3.00
1/
grw gIs pef n,If /-, �� MECH.CONT. LIC.NO. MECH./f�G w,Y..T' 7 ?/ TOTAL �� TOTAL
Signatu&1of Applicant/Contractor Date
INSPECTOR COPY