C7065 APPLICANT'TO FILL IN INFORMATION W-ITHIN RED LINES - USE BALL POINT PEN ONLY
' BU LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING _ , APPLICATION & PERMIT 7065
�( 'ADDRESS w72 BUILDING - ELECTRICAL-PLUMBING -MECHANICAL
OwNER'Sp PLAN CHECK VALIDATION
NAME )L /�q 0 /DU DTV• ELECTRIC PERMIT FEE
• �-2 DAv7D K CHu/PRONE _ 5`y-
j CONTRACTORS UTLETS-SWITCHES-RECEP 5.00/1.00 G �71� I/70
J NAME'1 C�
ppp- LIC.NO. LIGHTING FIXTURES 5.00/1.00 /� Q
ADDRESS aona PPLIANCES)-RESIDENTIAL 4.00
�- ----" a _,PHONE PANELS 7�' 5.00 DATE OF APPLICATION
I ARCHITECT SIGNS �,. 1 6.00 PLAN CHECK FEE P.C.NO.
}. OH
Yy ENGINEER
LIC,No. NS TRANS. 3.00
ADRC OR DRESS
ENG. SPE IAL CIRCUIT S.00 PERMIT VALIDATION
nF L . METER OR POLE INS. 15.00
AESNP$ [f MOTORS SEE FEE SCH. eti S
ADDRESS
SERVICE CHANGE 1170.00 y(_
/.
or LICENSED CONTRACTORS DECLARATION t -� 3� �a J
ar u u I hereby affirm that I am licensed under provisions of Chapter 9 ', 1` ISSUANCE DATE
N a N (Commencing with Section 7000)of Division 3 of the Business and - "BbOG. ELECT. PLG. I 'MECH.
F m z Professions Code,and my license is in full force and effect.
z o w - License Class Lie.Number - Q� �\ � 7✓I
o m F w Dale Contractor
¢ y s ` �`"•., BUILDING PERMIT
r¢
or or ¢ OWNER-BUILDER DECLARATION INFORMATION
Aoa " MISC.- REFER TO ORD
w 3 LL r I hereby affirm that I am exempt from the Contractor's License VALUATION SIFTS
F u O 4 Law for lire following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE6 / \
Code:Any city or county which requires a permit to construct.alter, .00 p-/
or ¢ < improve,demolish,or repair any structure,prior In its issuance,also ELEC.CONTR. LIC.NO. ELEC.
ve
0 ¢ ¢quires the applicant for such permit to file a signed statement that - TOTAL PERMIT TO
a w w he is licensed pursuant to the provisions of the Contract i s License
Fzi
Law(Chapter IT(commencing with Suction 7000)of Division 3 of the
¢ Business dad Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r o IhC hasis for the alleged exemption.Any violation ol'Section 7031.5 5 TYP ONSTR.
n ; byunyapplicanl for a permit subjects the applicant to a Civil penalty WATER (EA.)�4.00
of not more than five hundred dollars(5500).): ALTER-DRAIN&VENT-
❑ 1,us 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 structure is not
iniended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractors License Law does not apply to an owner of 4Z- 3
property who builds or improves thereon,and who docs such work, FIXTURES-PER TRAP 4.00SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such Improve- ✓/
ments are not intended or offered for sale.IL however,the building GAS-EA.SYSTEM-1 1 NC.4 OUTLETS 4.00
or improvement is Tsold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or ire- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIALWASTE INTER. 20.00 12 IN El❑ I,as owner of the property,am exclusivelycontracling with
-livnsed contractors to constructthe project(Secs7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Pmfesssions Code:1'he Contracmr's License Law does not apply
to an owner of property who builds or improves Ihereom and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
CDmracts for such projects with a contractors)licensed pursuant m o
the Contractors License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL No.
❑ 1 am exempt under Sec. ,BAP.C.for this
r I WATER HEATER W/VENT 4.00
. reason -
Owncr_ UatC WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
111 IISRS'COM NNSA'I'ION DECLARA'IION - WATER TREATING EQUIP. 4.00
Ihereby uffntri that 1 have a certificate ofconsent to sell'insore' ZONING ENG.SITE NO.
or a Certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec 3500,Lab.C.L
Policy No. Company -
O ❑ Cmtircd Copy is hereby furnished. / J FIRE SPRINK ENERGY T 24
Z 2 ❑ Certified yolD. its filed with the city inspection division.
O CIi R'fI PICATE OI'EXEMPTION FROM WORKERS'Applicant `` MISC.- REFER TO ORD. Y(] NE] Y ❑ N�
T PERMIT ISSUANCE 6.00 FLOOD ZONE A.LU.C.
`{i
5w T_ -1,,COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG, Y N Y N❑.
-6. O IT his section need not be completed if the permit is for one TOTAL
�.2 hundred delta,,CS 100)or less.)
FJ'O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued, I shall not employ any person in any manner so as to
O become subject To the Workers'Compensation Laws of California.
U.1 Date Applicant ALTER OR ADD TO MECH. ,''4:00 BUILDING
} rn NOTICE TO APPLICANT: If,after making this Certificate OFF. -
F" Z Croption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisiure 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.M) 3.00
C-ONS'I'RUC'HON LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE .1,4 QV
I hereby affirm that there is a emot"ction lending agency for EXHAUST HOOD(WITH DUCT) 2.00 2 -
the pedianlanee of the work for which this permit Is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3097,Civ.Ci 1. 7
' Loader's Nome HEATING UNIT(OV ER 100,000 B.T.U.)7.50 ELECTRIC 6 017
Lender's Addre is
1 certify that I Have read INS application and state that the above p VENTILATION FAN (SINGLE) 3.00 --
• information is correct. I agree to comply with all city and county I PLUMBING q �
ordinances and stale laws relating to building Construction, and BOILER-COME(3 H.P.or 100,000 B.T.U.) 4.00 O
hereby authori a representatives of this city l0 enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL f�-
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
may in any way accrue against City in consequence of the -PERMIT ISSUANCE '`3.00 J � pZl�l
gra yyqqg of this pen MECH.CONT.\ LIC.NO. / MECH.
�IJOA /�9f \ TOTAL a� J TOTAL j�
$ig�i4turc of Applicant/ Ontractor Dat
INSPECT. CSO