7124 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDH NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDINGAPPLICATION & PERMIT
VIp AppnEso �� I' 7124
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
Ow EP's PLAN CHECK VALIDATION
NAJE CITY. ELECTRIC PERMIT FEE
�'• � PMONE
c NElAcrORS _ OUTLETS-SWITCHES-RECEP 5.00/1.00
NAME SS
ILIO.No.7./ LIGHTING FIXTURES 5.00/1.00
J r-ONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00
AopREss^ ,/ ca
FI/ .C��SE �r 'PHONE` zj%7 PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO,
OR
E NGINEEH C
'LIC.No. SIGNS TRANS. 3.00
ARCH,OR ENG. PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANTSmonE5t - T MOTORS SEE FEE SCH.
AOORE / �r/] k
SERVICE CHANGE - 10.00 //�i�(JI/ (Js
wo o LICENSED CONTRACTORS DECLARATION
rt v U I herehy affirm Ilmt Iran licensed under provisions of Chapter 9 ISSUANCE DATE
(cvinlnencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. P MECH.
F w i Professions Code,andj by icense is in full force and effect. ❑ ❑ 1:1- z o - License Cla Lie.Number
o F Date Contractor
BUILDING PERMIT
a, w a OW'NI!R-BUILDER DECLARATION INFORMATION
oa MISC. REFER TO ORD
X LL 1 hereby affirm that 1 an,exempt (rola the Contractor's License - VALUATION $/FT.
FLLoa Law him the lollowingrcalm.fisc,.7031.5,Ifusinessand Professions PERMIT ISSUANCE 6.00
Code:Any city or County which inquires a permit to construct,alter,
QQ Q 2 Improve,demolish,or repair any structure,prior to Its Issuance,also ELEG,CONTR. LIG NO. ELEC.
K m S, requires the applicant for Such permit to file'a signed statement that TOTAL PERMIT TO
' w he is licensed pursuant to the provisions of the Contractor's License
F z i
Law(Chapter9(commencing with Section 7000)of Division 3 fthe
a Business and I'rol'essimu Code)or that he is exempt lhercl'rom and CITY. PLUMBING PERMIT FEE
M es the basis for the alleged exemption.Any violation Of Section7031.5 STORIES TYPE CONSTR.
d5,: °s by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 4.00
of mol more than Five hundred doll...(S500).):
❑ I,as owner of the properpt 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
intended or offered for sale(Sec. 7044, Business and Nol'essions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Codd The Contractor's License Law docs not apply m an owner of
property who builds or improves thereon, ,,it who docs such work FIXTURES-PER TRAP 4.00 SU FT FLOOR AREA TOTAL ACREAGE
• himself or3hmugh his own employees,provided that such improve
meats are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 1 NC.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 the burden of proving that Ire did not build or im- - RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the Property,ani exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed connuoton to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5,00 ASSESSORS PARCEL NO.
and Professions Code I'lie Contractor's License Law does not apply
loan owner of properly who builds or improves(hereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contra,is for such projects with a comractoAs)licensed pursuant to
,be Contractor's License Law. SEWER-SANITARY-STORM V-STORM EA.200ft/B.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,BAP.C.for this WATER HEATER 111 4.00
reason
Owner late WATER SYSTEM .4.00 ACC.DATE ACC.FILE NO.
WORKF.RS'COMPI-NSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have acvniric,tc ofconsenl to self-insure,
or a ic,ldcate of Workers'Compensation Insurance,ora certified ZONING ENG.SITE NO.
ropy thereof(See.3801T.1-ah.C..
r Policy No. zCoinpany
Q ❑ CZ,flficd cop}*is.huu6q urnish,d. FIRE SPRINK ENERGY T 24
z Z ❑ ity'im"sctiun division.
O ApplicCc'i4,ay
z l,C MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
CC rn CFRI'IFICA'1'170171i XIiMPTION PROM WORKERS' PERMIT ISSUANCE 6.00 FLOODZONE A.L.U.C.
LOU > COMPBNSAIION INSURANCE PLG.CONTR. LIC.NO. PLO.
d o ('I his section need mol he complcied if the permit is for one - TOTA �� Y❑ N❑ Y ❑ N❑
::� Z hundred dollars($100)or lass.)
U O I certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL f- mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensmion Laws of California.
UJ Q. Dan' Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} rn NOl'ICI:TO APPLICANT': If,after making this Certificate of 1ix-
Z_ cmption,you should become subject to the Workers'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 10=11F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
1 hereby affirm That there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performmnce of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
1 Certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. 1 agree to comply with all city and county PLUMBING
ordinances :rad state laws'reWting to building construction, and BOILER-COUP(3 H.P.or 100,000 B.T.U.) 4.00
hereby auihorirc represavaiives of this city m enter, upon the BOILER-COMP (Over 100.000 BTU)SEE FEE SCH. MECHANICAL
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 said City in consequence of the PERMIT ISSUANCE 3.00
But Ingo this permit. ECH.CONT, LIC.NO. MECH.
I �y TOTAL TOTAL
\/ Signature of Applicant/Contrae[ r' Uutc
INSPECTOR COPY