7272 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
1 BUILDING PROJECT IDENTIFICATION _ PERMIT NUMBER
111111NG / APPLICATION & PERMIT
A KESS BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 7272
it 7 u
�NIEH'S t UO,D %/J(QC PLAN CHECK VALIDATION
NAME 1 '\ /(- QTY. ELECTRIC PERMIT FEE
� PHONE�, I -O O
CONTRACTOR
NAME UTLETS-SWITCHES-RECEP 5.00/1.00
NAME �
/ Le LIE.No. LIGHTING FIXTURES 5.00/1.00
ro RACTOR'S PPLIANCES-RESIDENTIAL `4"00
AooREss V V
l 00 1-4enede. PHONE 7 �� PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ON
LIc,No, SIGNS TRANS. 3.00 4
ARCH,OR ENG SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
SS
ZIP TEMP.METER OR POLE INS. 15.00 �
APPLICANT MOTORS SEE FEE SCH.
AOVRES
t} SERVICE CHANGE 10.00
00 LICENSh?U CONTRACTORS DECLARATION
a v U I hereby uflirm'thel I am licensed under provisions o f Chapter 9 ; ISSUANCE GATE
(cmnmemmng with Section 7000)of Division 3 of the Business and BL G. ELECT. I PLG. MECH.
F w z Nofessions Code,and my Ii"a.is in full force and effect.
Qz o License ClasLic.Number
❑
N ( ❑ ❑
a m E J / BUILDING PERMIT
wa OWNER-BUILDER DECLARATION - INFORMATION
E: D1UMISC.- REFER TO ORD
I hereby m irm that I um exempt from the Contractors License VALUATION $/FT.
u_ o j Law for the following reason.(Sec 703 1.5,Business and I'rol'essions PERMIT ISSUANCE 6.00
Code:Any city Or county which reyuires a permit I.tVm,UmCL2her,
re eaimprove,demolish,or repair any 3tructurn,prior to its issuance,also ELEC.CONTR. LIC.NO ELEC. Pv �V
A, 0DLL requires the applicant for such p{mi(to file a signed statement that TOTAL PERMIT T
u w hu is licensed pursuant to the fit visions'of the Contractor's License
H i
Law(Chapter 9(commencing with Sect ion 7000)of Division 3 ofthe
e Business and Professions Code).,'that he is exempt thcrefmm and CITY. PLUMBING PERMIT FEE
¢ r o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
d ; °' by any applicant lir a permit subjechthe applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(S500).).
U 1,as than
of the property,or rey,employces with wage,ae BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.QNITS
�I "ca,sole co..tpensW ion,will do the work,and the structure is nut
intended or offered for sale (Sec 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,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 F IXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve.
Urns are not intended or offered for sale,If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
L mrprovemu it is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDINGUSE
builder will have the burden of proving that he did not build or im- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 RE ❑ ❑
❑ I,as owner of the property,are exclusively contracting with
licensed.contractor 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 Luw does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OV ER 5(EA.) 1.00
con tracComeaorsuchLicenje ts Lwithecolnracmrts)licenced pursuant to SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
the Cont for s License Law.
O l um exempt under Sec.-.B.&P.C.for this WATER HEATER W/VENT - 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COM PENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby allinn that I huvc a certificate of consaM to self-insure, ZONING ENG.SITE NO-
certificatc of Workers Compensation Insurance,or a certified
copy thereof(Sec.3800,Wh.C.).
Policy No. -
Company-0 ❑ Cerified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z_ Z i e,Rficd cypy is file thnhc city insgcclion division. MISC. REFER TO ORD. v N� Y [:] N�
O� Ap cam !v T _//TYG�r.r"ro"'
~ in PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
cc �` ,� C:R1'114CATE OF IiXIi NIPTION FROM WORKERS'
LU CONII'ENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. y N v N
CL O 11 his seahon need not be conlplated if tire fo
e permit is r one TOTAL
Z hundred dollars IS 100)or lcssJ ,
U O 1 certify that in the performance of tire work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H 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.
O w [)are-A beam BUILDING <j�
Applicant ALTER OR ADD TO MECH. 4.00
} w NOl'ICE TO APPLICANT': If,after nmking this Certificate of Ex-
rZ umption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK' / O
provisions of the Labor Code, you must forthwith comply'veith FEE (O
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO lOf]OOC.F.M-) 3.00 GG
C'ONSTRUC'T ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 5.00 1 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(See. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.P.50 ELECTRIC
hander's AAdress
1 certify that I have read this application and stale 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 authorim representatives of this city W enter upon tie BOILER-COMP(Over 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
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00 %
granting of this permit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL S36
Signature o Appli an[/Contractor Date
INSPECTOR COPY