7054 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDINGAPPLICATION & PERMIT
,A91RE$s parlKp
r OIII PI I- BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 7054
OWNER'S PLAN CHECK VALIDATION jy
-'L NAME a2 QTY. ELECTRIC PERMIT FEE PHONE -1
CONTRACTORS UTLETS
-SWITCHES-RECEP 5.00/1.00
NAME
Qn LIE.... 2 LIGHTING FIXTURES 5.00/1.00
-�
ADDRESS ('IER�,4� PPLIANCES-RESIDENTIAL 4.00
A30 0 IA Logy) RA PHONE 97-5 PANELS 5.00 DATE OF APPLICATION
ARCHITECTSIGN$ 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3-00
ADo'ESS ENC' SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
ADDRESSTs MOTORS SEE FEE SCH.
SERVICE CHANGE y10.00
0
0
oI ,
Foo LICIiNSIiU CONIRACIORS DECLARATION !'
is U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
Na N (commencing will,Section 7000)of Division 3 of the Business and ELECT. PLG. MECH.
F D z 1'rofCode og I my license is in full force a ((fyct.
i o u,- I.iicnse ClassL�6_�LM Z.ic.Number I (62 ❑ ❑ ❑
g v,F DBIe_7�� Canlradar yµ_pW
e, s BUILDING PERMIT
IS a OWNER-BUILDER UECLA RATION INFORMATION
woA MISC.- REFER TO ORD
g u. H I hereby collo that 1 am exempt from the incssaotor's License vq LUATION S/FT.
FLLNQ. Law for the following reason. 7031.5,Businessand Professions PERMIT ISSUANCE 6.00
Code:Any city or county which re9uiresa permiuo construct.alter,
2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NQ ELEC. /
-O E requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
n w m he is licensed pursuant to the provisions of the Contractor's Licerw
F z i
Law(Chap ter 9(eumme ncing wi th Sect ion 7000)of D ivision 3 of l h c
Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
r o lite basis for the alleged exemption.Any violation of Section 7031.5 IES TYPE CONSTR.
by any applicant for a permit subjects tele applicant ton civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of nal more than five hundred dollars IS 500).):
❑ L as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.caouP RES.,u NtTs
their sole compensation,will do the work,and the structure is non
intended or offered for sale(Sec. 7044, Business and Ponel,mas DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:"1'he Contractor's License Law dues 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 improve-
ments are not intended or offered for sale,IL however,file building 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 have lite burden of proving that he did not build Or im-
pr�veforpar poseofolc). INDUSTRIALWASTE INTER' 20.00 E IND CON PD Omer
❑ L as owner of the property,am exclusively contracting with ❑ ❑ E3licensed contractors it) Construct the project(Sec 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 AZS0 PARCEL No.
and Professions Code"I'he Conhad.r's License Law does not apply .
Ili an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OV ER 5(EA.) 1.00
contracts for such projects with a contractor(%)licensed purlmnt to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Scc. ,B.&I'.C.tisr mi% I
WATER HEATER W/VENT 4.00
On
Owner Date WATER SYSTEM 4.0 /" ACC.DATE ACC.FILE NO,
WORKERS'CO,M PI'NSATIoN DECLARA IION WATER TREATING EQUIP. 4.00
- Ihereby affirm that l have a certificate of consent to self-insure, ZONING
or a eertifical,of Worker'Compensation Insurance,or a certified ENG.SITE NO.
copy tile, 1 l e.3800. �y � �'
}/ I'OIICY No -JI&CIon,hY�L[)iQ_.y W n
/ ❑ Certified copy is hereby l urnishcd. FIRE SPRINK ENERGY T-24
Ce'z 2 App lcanatif icl��op wit^lire city inspection division. MISC.- REFER TO ORD. �, ❑ ❑ ❑ ❑
n� �( ( V N V N
F IT}� P fIT iTN F/ IN'bRAL�2�'�jRERRMIT ISSUANCE 6.00 P FLOOD ZONE A.L.U.C.
LU CISR'I' OMSE SAII 1
W C(1111not be I'ism INSURANCE PLG.CONTE. LIC.NO. PLG. D I� v N v N
d O fl his senior, need not be completed if the permit ig.for one TOTAL ❑ ❑ ❑ ❑
:D Z hundred dollars(S1001 orless I '
U O 1 certify that in the performance of the work for which this per, OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mil is issued, I shall not employ any person in any manner so as to
V become subject to the Workers'Compenmtion Laws of California. ,..t`
U as Dam Applicant ALTER OR ADD TO MECH. 4.00 BUILDING /WL/J
} in NOIICIi"1'O APPLICANI If,after making this Certificate of Ex
p_ Z emption.you should became subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of m
the Labor Code. you list forthwith comply with FEE -
U sucll provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10=C.F.NL) 3.00
CONS TRUCIION LI'NDINO AGENCY AIR HANDLING UNIT(OVER I0)000C.F.M.) 5.00 SEISMIC FEE /
I hereby affirm that thcr, is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Ci,.0-). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.P.50
Lender's Address • ELECTRIC
I certify Ihat I have read this application and lain,that the above VENTILATION FAN (SINGLE) 3.00
infornutiun is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-OOMP(3 H.P.or 100,000 B.T.U.) 4.00 -
hereby authorize representatives of this city no enter upon the BOILER-COMP(Over t00,000BTU)SEE FEE SCH. MECHANICAL
abovemrentioned properly for inspection purposes.
(We) agree to lav,, indemnify and keep harpies true City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, Costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against said City in consequence ofdhc
gmnlingofthispennif. MECH.CONT. LIC.NO. MECH.
1 ! ,i f.__ / � s. TOTAL TOTAL
Sig�dtire of Applcanl Contractor eT T'U1a R,
INSPECTOR COPY