7092 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT IDENTIFICATION PERMIT NUMBER
BDDNE'UILDING APPLICATION & PERMIT 7092
I
BUILDING - ELECTRICAL-PLUMBING -MECHANICAL
Ow E 'S IPLAN CHECK VALIDATION
NAACITY. ELECTRIC PERMIT FEET
PHONE
NAME ALTDRs OUTLETS-SWITCHES-RECEP 5.00/1.00
pc� la IC.No. LIGHTING FIXTURES 5.00/1.00
/
CONTRACTOR SAPPLIANCES-RESIDENTIAL 4.00
DDRE
ASS C 1' b p
/ 60 ✓ IM1 I L C1 PHONE 3 =jam p % PANELS S.00 GATE OF APPLICATION
AR RI ELT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER LIC.NO. SIGNS TRANS. 3.00 _
'S�
ADDRESS ENA- SPECIAL CIRCUIT 5.00 ' PERMIT VALIDATION
zIPr FrEMP.METER OR POLE INS. 15.00 t.
APPLICANT$
ADDRESS MOTORS SEE FEE SCH.
'- I
SERVICE CHANGE 10.00
o ¢,z
I.,
o Q LICENSED CONTRACTORS DECLARATION
a v H I hereby affirm that I am licensed under provisions of Chapter 9 ISSUAN E DATE
y a
(commencing with Section 7000)of Div'isiou 3 of the Business and BLDG. ELECT. P G. MECH.
F �Ize Professions Code .,it ylicense is in full for- und�cc(
z o License Class_L��_4_Lic.Number-
i, �S9 5 S 3
z w Dan I--/4,-%G Contractor
Y BUILDING PERMIT
w a OWNER-BUILDER DECLARATION INFORMATION
wo A ° MISC.- REFER TO ORD
; H I hereby collo (hal I oarnn exempt from the Contioc,and Po License
F .. of Low lar lire following mason.f5cc.703L5,Itusincssand Pvoressions PERMIT ISSUANCE 6.00 VALUATION $/Pr.
f �0E Code:Any city orcounly which requires a permit to construct,alter, ELEC.CONTR. LIG NO.
a O improve,demolish,or repair any structure,prior to its issuance,also EL C.
o.
- O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w m he is licensed purssount to the provisions of the Contractor's License
F z i
Law(Chapter 9(commencingwith Section 7000)of Division 3 of the
a Rosiness and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
F Oo the hasis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a.a ; f° by any applicant for a Permit subjects the applicant to a civilpenulty ALTER-DRAINSt VENT-WATER (EA.) 4.00
of not more than rive hundred dollars($5000:
❑ h as owner of the properly,or my employees with wage's as BACK F LOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
tr
their sole compensation,will do the work,and the sucture is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractork 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 50.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such impmve-
incusarenot intended or offered for sale.If.however,the thudding, GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improvement is Sold within one year of completion,the owner- - GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will Imse the burden of Provo,that he did ria build or iin-
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 20.00 REs IND Cory PB omen
❑ 1,as owner of the property,an,exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors r, construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:"fire Contractor's License Law does not apply
loan owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a conlmetorfs)licensed pursuant to
the C' ntmnor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
II amexempt under Sec. ,If.&P.C.for this WATER HEATER WIVENT4.00
IeasnllIf
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE N0.
WORKI'RS'COMPI!NSAT'ION DECLARAHON WATER TREATING EQUIP. 4.00
r1 hereby atc if that I have a cerrsai to Insurance,or.censure, ZONING ENG.SITE NO.
ca certby to of Workers'Compensation Insurance,t a cerl'une,
opy thereof(Sec.300,Lab.C.).
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T"24
ZZ 17 C'ertif'ied copy is filed with lire city inspection division. MISC.- REFER TO ORD.
.O Applicant Y❑ IN Y ❑ N❑
iry CIiRT119CA1'Ii OI'EXIiA1P1'ION PROM WORKERS' PERMIT ISSUANCE 6.00 FLOOO ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL O ('f his section need not be completed if the permit is for one TOTAL Y❑ N❑ v❑ IN
Z) Z hundred dollars IS 100)or less.)
U O I certify that in the performance of the work for which this per- OTY. 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 tire Workers'Compensation Laws of California.
Ed Datc Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} W NO]ICE 1"0 APPLICANT': If,after making this Certificate or Ex-
♦- Z emption,you should become subject to the Workeni 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 10000C.F.M.) 3.00
CONS'I'RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=11 F.M.) 5.00 SEISMIC FEE
I hereby alfirn that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance or lire work for which this permit is issued(Sec. MICROFILM
3097.Civ.CJ, I HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
NHEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's NameAddres ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and cormty PLUMBING
ordinances and slate laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby mllhorim representatives or [his city lu enter upon the 601 LER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep 113rniluss the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
rimy in any way accrue said City in Consequence of the PERMIT ISSUANCE 3.00
rat lilt MECH.CONT. LC.NO. MECH. O
�' D TOTAL TOTAL
I ,nature of APPltcunl/ ontractor Date -
Ix/ INSPECTOR COPY