C7131 l
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
' -�✓" 'BU I LD ING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
A-REgs �+ Cyi 7131
c„ - ESS O��IPa BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME C/� 1 CH
QTY. ELECTRIC PERMIT FEE c 21'�
zjoSl PH MVI PHONEJ -3
coME NTRAcroRs UTLETS-SWITCHES-RECEP 5.00/1.00
NA �p 7,
�Ow
LIC.NO. LIGHTING FIXTURES 5.00/1.00 ( V--V
CONTRACTOR 5 PPLIANCES-RESIDENTIAL 4.00
AODNM
402oNwLAJSgw NF -74(P-66g I PANELS 5.00 DATE OF APPLICATION
ARCH17ECT I SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER 1�oSkr„S fH i.xQ3 vS LIC.NO. C3S12 SIGNS TRANS. 3.00
'•� ARCH.OR ENG' SPECIAL CIRCUIT S.QQ PERMIT VALIDATION
..DRESS �1
, 01 Sf.J A✓2 Sp O P 9S 2 EMP.METER OR POLE INS. 15.00
ono
iesTS MOTORS .I SEEFEESCH. � l
^ A i
SERVICE CHANGE 10.00
Foo LICENSED CONTRACTORS DECLARATION 1�SJ
¢ vI hereby affirm Thal I am licensed under provisions of Chapter 9 Nix, ISSUANCE DATE
uaHi< m (commencing with Section 7000)of Division 3 of the Business and BLDG- ELECT.1 PLG, MECH.
F mz Nofessiuns Code,and my license is in full force and effect. rI
z o as- License ClassLie.Number
g zUatc Contractor
a y 2 BUILDING PERMIT
¢ ¢w OWNER-BUILDER DECLARATION INFORMATION
w 0 1 hereby alflrm that I am exempt from the Contractor's License 1. MISC.- REFER TO ORD
u O as j law for fire(alluwin VALUATION $/FT.
F _ sreaeon.ISec.70J1.5,tlusinessand Professions PERMIT ISSUANCE 6.00
Code:Any coyoremonty whichmquiresapermittoconstrucLalter,
¢-¢ G 2 improve,demolish,of repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. ! �C T
O a, requires the applicant for such permit to file a signed statement that )'1 TOTAL/�(� PERMIT TO
d w m he is licensed pursuant to the provisions of the Contractor's License s(N
F z In Law(Chapter 9(cummencinswith Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE LG
sio
¢ F o the basis for the alleged exemption.Any violation of Section 7031.5 ST ES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty
ALTER-DRAIN& VENT-WATER (EA.) 4.00
of not more than five hundred dollars(my'e ): u� S H
❑ Las owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compered ion,will(S the work,and the and
Professions
is not
Code: I or offeredtract for sale (Sec. doe Business and Professions DRAINS-FLOOR,ROOF,AREA, 4.00 t,
Code'ILc Who
builds r License Law docs not apply to an owner of ..
1 himself whD builds or improves Thereon,and Who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
hints,))'or through bis own employees,provided that such improve-
•, moms are Out intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 4.00 33a0 'it.
or imprwenmel is sold within enc year of completion'Ire owner- '
builder will have. the burden of proving that he did not build or int- GAS-EA.SYSTEM-OVER 4(EA.1 .00 BUILDING USE
Prov,fie purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 RES IND CON PB ower
❑ L;is owner of the property,an exclusively contracting with ❑ ❑ ❑ ❑
licensed con meta... to instruct ate project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and E'rol'essiuns Codc:'I'lie Cam tartar's License Law dos not apply N
to an owner a(property who builds or approves thereon,and who LAWN SPRINKLERS-OVER 5(EAJ 1.00 3/-� ��- ��
lout acts for such pmjee is with contractor(s)licensed pursuant T to _
t he Con tmmoh l-kens,Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am •xem r a codeB'&P.C.for this WATER HEATER W/VENT 4.00 � b / �d
ruason
Owner Data WATER SYSTEM 4.00 ACC.GATE ACC FILE NO.
'ORKERS'COMPENSA110N DECLARATION WATER TREATING EQUIP. 4.00 \
I hereby affirmthat I have a certificate ufeonsent to self-insole. G x ZONING
or a certificate of Wrrkcrs'Compensation Insurance,or a certifiedENG.SITE NO.
copy thereaf(Sce.3800,Lab C.).
Policy No. Company
O ❑ Certified Copy is hereby furnished. FIRE SPRINK ENERGY T 24
z p Applicant
❑ Cetified copy is filed with the city inspection division. MISC-'- REFER TO ORD. =.`` N Y N
~ %a . PERMIT ISSUANCE'.. 6.00 6 �- FLO❑OD ZONE A.O.C. ❑
W CERTIFICATEOF EABION'INS FROM WORKERS' -
W �_ COMPIiNSATION INSURANCE: PLG.CONTR. LIC.NO. PLG. � r
C' C) (I info
his section need net be completed if the permit in ,one TOTAL 7,f Y❑•. N❑ Y❑ N❑
Z) 2 hundred doll...IS 100)or bell.)
U O 1 artily tmt in Ire pe,lonemmet,of the work for which this per- QTY. MECHANICAL PERMIT - FEE FEE,SUMMARY I
LL 1- mit is issued,I .shall not employ any persudin any manner so as to
U
U become subject to the Workers Compensation Laws of California. BUILDING " ��I
UJ Dam Appliciud ALTER OR ADD TO MECH. 4.00
} to N(1TICli 'I'(l AI'I'LICAN'I': 11',alter making this Certificate of Ex-
Z_ emption,you should become subject to the Workers'Compensation APPLIANCE `;. 4.00 PLAN CHECK
provisions of the Labor Code, you must lixthwith comply with FEE
U each provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1000011F.M.) 3.00
CONS'I'RUCHON LENDING AGENCY AIR HANDLING UNIT(OVER I0,000C.F.M.) 5.00 SEISMIC FEE �'e74
1 hereby affirm Ret there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the perfonmanm of Ire work fiat which this permit is issued(Sec. MICROFILM
3097,Civ.C.LB��A HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name !J HEATING UNIT(OVER 100,000B.T.U.)7.50 _
Lender's Addrevv I^( P' za S3�
ELECTRIC O
I certify that l 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 county - PLUMBING =
ordinances and state laws relating to building construction,and • BOILER-COW 13 H.P.or 100,000 ELT 4.00 7f
hereby authorize representatives of this city to enter upon'fiit BOILER-COMP IOver 100.000 BTU)SEE FEE SCH. MECHANICAL A0
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 CONST.TAX aLG
may in any way accrue a ainst said City in consequence of the PERMIT ISSUANCE - 3.00 3� /
grant IT of lhis,pprmiC� 1i3�8S MECH.CONT. LIQ NO. MECH.
�/ 1 �;;� TOTAL TOTAL
Si um ol Ipplicanl/Contractor Date
INSPECTOR COPY