C7207 AP?a (CANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
r (eu�yy r BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
ealLawG APPLICATION & PERMIT Cl'/
AOOHEaS�•'• 7-/07
%02�. P���� `LQo.�L BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 4
�C OWW�N9ERU FFF PLAN CHECK VALIDATION
• u' ,/,?, �� QTY. ELECTRIC PERMIT FEE
�'f(r�I-`.' M PHONE
CONTRACTORSXilsliUTLETS-SWITCHES-RECEP 5.00/1.00
NAME /
i G
/;4
L¢.No. �z ,1 LIGHTING FIXTURES 5.00/1.00
nooness oRs II'' �,/ ,I/Oz/SxU�Q PPLIANCES-RESIDENTIAL 4.00
S 5• X74�k,���4 }'�
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS - 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER (5
r%" LIC.No. SIGNS TRANS. 3.00
ARCH.OR Ervc. 241/-/g .9 SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
e~ i( zip W/ rrEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
/1 7 SERVICE CHANGE 10.00
Do LICENSED CONTRACTORS DECLARATION /
a o u I hefehy affirm that 1 am licensed under pravisiuns of Chapter 9 ISSUANCE DATE
m a w Icomnuvming with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H D z I'm fessions Code, I my license is in full force and effect.
o i m� Licaae Class Lic.Number
F m F J Dara-a,_ C'onlmctor
a s BUILDING PERMIT
¢ w a OWNER-BUILDER DECLARATION INFORMATION
A o AO flnm MISC.- REFER TO ORD
; n y I hereby afm that 1 aexempt frons the Contractor's License VALUATION
w $/FT.
asLaw let the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 6.00
P, Code:Any city or county which requiresa permit toconslTutt.alRq
QQ¢0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. 177GLP'ID
O a, requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
a w m he is licensed pursuant to the provisions of the Contractor's License
r z i
Law(Chapter 9mommenciagwith Section 7000)of Division 3 ofthe / V�C E'er
a Business and Professions Code)or Ilist he is exempt therefrom and QTY. PLUMBING PERMIT FEE
f i o
¢ m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
u : by any applicant for a permit subjects the applicant too civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00 •1 _S V,
of nor marc than five hundred dollars($SOOT). of
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS`
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 _ 3 �
Code:The Canrmclor's License Law dues not apply to an owner of
Property who builds or int proves lImmon,and who docs such work FIXTURES-PER TRAP 4.00 50,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
nwnrs are not intended or offered for sale.11,however,the building GAS-EA.SYSTEM-l1NC.40UTLETS 4.00
or improvement is sold within one year of completion, the owner- GAS-EASYSTEM-OVER 4 IEA) 100 BUILDING USE
builder will have the howlers of proving liar he did not build or im- . . .
RES IND CON PB Omer
prove for purpose id sale.(. INDUSTRIAL WASTE INTER. 20.00 RE IN ❑
❑ 1,as owner of Thu properly.am exclusively contmeting with
licensed Contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- I INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code: [lie Commetor's License Law does not apply _to an owner of property who builds or improves thereom and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00 3a 6
contracts for such projects with a contractons)licensed pursuant to
lire Cnmtmctor License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec. BAP.C.for this WATER HEATER W/VENT 4.00
reason 3 a G /
Owner Dat, WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPI[NSATIONDIiCLARATION WATER TREATING EQUIP. 4.00 -
I hereby affirm that I have a certificate of consent to self-insure. ZONING
or a certificate of Workers'Compensation Insurance,ur a certifieJ ENG.SITE NO.
,opt rnercl ffsee.3soo,Lan.C.). ;;x 2 S9 n/ / �o
Pace Na -
o ❑rCcrt tT pyllr pg�eppY(umishC FIRE SPRINK ENERGYT-24
z ❑ Certified n is Ileo it to city inspection division. MISC. REFER TO ORD.
O Applicant Y [] N❑ Y E] NE]
Fy PERMIT ISSUANCE 6.00 FLOOD zorvE A.L.0 c.
CI: 'I'I PIG1'fli Oh EXEMP1 IO. FROM WORKERS'
LU > COA11'IiNSATIOMINSij.RANCE PLG.CONTR. LIC.NO. PLG. Q ❑ V ❑ ❑
CL O (this section neer) not be completed if the permit is for one TOTAL V N N
Z) Z hon dyed dollars IS 100)or lcvxJ
U O 1 certify that in tiro performance of the work for which this r- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall mar employ any person ipe
n an manner so as to
U bccoy.l,{{ntc bjcc ru rhe Wnrkcrw Comp 1:y'riot 1a sof California.
0 a Date. npph°um p, r i '. ,ffir ALTER OR ADD TO MECH. 4.00 BUILDING 6.,?�'^�
} m NO Cli I(YYA_ITLICAN'I': If,Nrcr'nw,4 it ng this CertLr;+it 3m m fix-
Z engrtiaa,you should bcamne subjectto rhe Workers' ompensalion APPLIANCE 4.00 PLAN CHECK
pravisiuns o1' the Labor Code, you must forthwith comply with FEE
U such provisions or this perinit shall be deemed revoked. AIR HANDLING UNIT(TO 10)000CF.M.) 3.00
CONST'RUC'TION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 5.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00 r
it,, performance of the work for which it permit is issued(Sec. MICROFILM
30'(7,Civ.C.). �J// (� HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's .C.L S�T/s la^ HEATING UNIT(OVER 100,000B.T.U.)7.50
- Lender's nddrcss_ ELECTRIC F
I certify that l hav,read this app 11 cation s�e that above VENTILATION PAN (SINGLE) 3.00
information is correct. 1 agree to comply with all 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 aullariee representatives of this city to enter upon the BOILER-COMP (Over 100.000 BTUI SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(we) agree 10 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 q�av
may in any way accrue a Lost said City in consequence of the
gmnli Oft permit MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL //3S""
Signa arc of Ap Cam/Comr i Dale
INSPECTOR COPY