7259 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT 1 DENTI FICATION
PERMIT NUMBER
BUILDING APPLICATION & PERMIT 72rr9
ADDRESS ( G``��
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNERS PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
• PHONE
eeia"nsERACT�O/Rs
OUTLETS-SWITCHES-RECEP 5.00/1.00
�/�.✓.'1aA,141T1 C, SILII.
CONTRACTOR No. LIGHTING FIXTURES 5.00/1.00
- c.oms APPLIANCES-RESIDENTIAL 4.00
CONTRAS
(> O ZALjICtRQ ONE - PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
O
OR pT
ENGINEER ft Y / 1 1
A LIC.No.aibb SIGNS TRANS. 3.00
nooA�OR ENc. SPECIALCIRCUIT 5.00
PERMIT VALIDATION
J ZOA . P10U_1A ZIPy TEMP.METER OR POLE INS. 15.00 r
APPLICANTS
NrS MOTORS SEE FEE SCH. ..J
ADDRESS ��I
bv0-es �1J�(c((. yc.OD SERVICE CHANGE 10.00/
w o 2 LICENSED CON'1'RACI'ORS DECLARATION Q
a U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE M
z w Lcu nntencing with Section 70001 of Division 3 of the Business and
rn ¢ d SLUG. ELECT. PLG. MECH.
H i Pfofc.aslnnx Cy,�dyy yyn I�nnyyI}q%'N ix in full far gtjt� t y� n
z 0 m - hicaTse CIasL�2p )`ly� N `'{ U�UJ
oh=w D'ele .J_,,,,_�Cbntractor�c� t�
ams ( CK BUILDING PERMIT
¢ ¢ a
OWNER-BUILDER DECLARATION RATION
A o a U INFORMATION
w ; G I hereby ctCLL that 1 am exempt from file Contractor's Liccnxe MISC.- REFER TO ORD vn,unnoN
t- ec0j Low for the W howingraason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00 $/FT.
i Code:Any city oreounly which requiresapermit toconstraa,xller. _4 D ;I
Q Q aimprove,demolish,or repair any structure,prior to its Issuance.also ELEC.CONTR. LIC.NO. ELEG
O M requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
a w m" he is licensed pursuant to the provisions of the Contractor's License
H z i Law(Chapter 9(commePcing with Section 7000)of Division 3 ofthe
io INlsiness and Professions Code)or that he is exmnpt therefrmn and OTY. PLUMBING PERMIT FEE Z fT
(c I- C, the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a _ by any applicant for a permit subjects the applicant loa civil penalty ALTER-DRAIN -WATER (EA.) 4.00
L.
of not more than five hundred dollars(5500).):
❑ 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 st Torture is not
Intended or offered lot 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 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such In'
ro
Poise- GAS-EA.SYSTEM-1 INC.40UTLETS 4.00
mems are not intended or offered for sale.If,however,the building
or improvement is sold within one yeor of completion,the owner- z
builder will have file burden of proving that he did nut build or int- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
Prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 RES IND CON PB Omer
❑ I,as owner of the property,am exclusively'contracting with ❑ ❑ ❑ [D ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code.:1'he 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 forsuch projects with a contmclons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,IT&P.C.for this WATER HEATER W/VENT 4.00 -
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSA'FION DECLARATION WATER TREATING EQUIP. ;Y4.00
I hereby affirm that I have a certificate of consent to self-insure. ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy her l$ec..�8-OQs LabC.)1.
r Policy No. puny
O ❑ Certifiedcnpyisherebyfunlished. JIV FIRE SPR INK ENERGY T 24
z O Apjp Cl au ified copy i filed wi h twit i e 'o 'vision. MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N❑
Fy lit -"L PERMIT ISSUANCE 6.00 - FLOOD ZONE A.L.U.C.
CC L2 Cf°RTIFI COMPENSATION
INS'PROM WORKERS'
W � COMPENSATION INSURANCIi PLG.CONTR.' LIC.N0. PLG. !/�
0 ('Phis section need not be completed if the Permit is for one TOTAL YID N❑ Y E] N❑
hundred dollars IS 100)or less,)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
Id- F 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.
U a Dutc Applicant - ALTER OR ADD TO MECH. 4.00 BUILDING -
} N NO'I'ICI!TO APPLICANT: If,after making This Certificate of Ex-
�. ? emotion,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.N7) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE s�
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work In,which this permit is issued(Sec. MICROFILM
3097,Civ C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's AddreHEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
ss
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 3.00 (h1
. information is correct. 1 agree to comply with:dl 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 authorize representatives of this city to enter upon the
abuve-mentioned property for inspection purposes. BOILER-COMP(Over 100,000BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
main an wuy accrue against City m consequence of the
gryanting this permit. MECH.CONT. LIC.NO. MECH. /
Z TOTAL TOTAL
Si ature of App tractor Date
INSPECTOR COPY