7020 APPLICANT T FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FICATION PERMIT NUMBER
<• BUILDING APPLICATION & PERMIT
)o j's BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 7020
wNER's PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
�• f PHONE
CONTRACTORS [OUTLETS-SWITCHES-RECEP 5.00/1.00
NA coy
NO. lq} LIGHTING FIXTURES 5.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
CONTRA
e PRONE -�� PANELS -"` 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 1- PLAN CHECK FEE P.C.NO.
OR
uc.No. SIGNS
ENGINEER TRANS. 3.00
ARC ess ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00 PAID
APPLICANTS MOTORS SEE FEE SCH.
.AOOREs3.. w SERVICE CHANGE 10.00
' JUN 2 019A5
F 0 0 LICENSE
D CONT-RACTORS U[CLARATION .{
a v u I hereby nftinn that I am licensed under p,.,i,io,,S.f Ch.plc,9 ISSUA OSCUP"1
100
a va ( on m n ng with Section 7000)Of Dwlvon 3 f the Business aad T - g ELECT. _PLG.
,.H y Z I tfes.Ions( p'e'f uY�y.1� ens,Lt lo-lullfor Z d' feu,/'l -< '
O i m 0 I e - Class LicNumher� -- ❑
H w H W UatC COnlmctof-,/� -(�-�-
¢ y s w - -""e+ BUILDING PERMI
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OWN. -BUILDER UECLARA'fION INFORMATION
A OAO - MISC.- REFER TO ORD
w g u y I hereby affirm that I am exempt from the Contractors License VALUATION $/FT.
Hu0 J Law for the following reason.(Sec.703L5,Business Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires permit to Cunstoad.aIle,,
Qaa Q Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
0 0, requires the applicant lin such permit In file a signed statement(hal TOTAL P gMfT TO
o
h
w m e is licensed pursuant to the Previsions of tilei s ContractoLicense
rzs- Lag,(Chapter 9(commencing with Section 7000)of0ivisiun 3 of the
¢ Business and PRalessims Code)or that lie is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ I o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
d ;m by any applicant fur a permit subjects the applicantoacivil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
(heir sole compensation,will do(he work,and the structure Is not
intended or offered for sale(See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Code The Contractor's License Law does not apply to an owner of
pa h Perty who builds or improves there Un,and who does such work F IXTURES-PER TRAP 4.00 50,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve
mints are not intended,,offered liar side.If.however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner GAS-EASYSTEM-OVER 4 (EA.) 100 BUILDING USE
builder will have (he burden of proving that the did not build or im- . . .
5 IND CON PB Omer
Prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 1:1 El E] 1:1
CI as owner of the property,am exclusively contracting with
licensed conlradon to construct the project(Sec.71344,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code The Contractor's License Law docs not apply
to an owner of property who builds or improves thereon,:and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
con mets for such projects with It contract arto licensed pursuant to
(ire Contractor's License law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lamexenlpltmdcr5ee. ,B.&P.C.torthis WATER HEATER W/VENT 4,00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACG FILE NO.
.W❑RKIiRS'COMPENSA'I'ION DECLARATION WATER TREATING EQUIP. 4.00
I hereby alfirnh (hut I have u cmlificum ofcomsenl Iu self-insure. ZONING
�1 ,9 Certificate f Workers Cnard,,isallOn last once.o(rgayceertified ENG.SITE NO.
OI y i ha,^�ht�T,�.cy&I rIV V _4..d� r O( .�. _ e
,...�..Pulmy Nsh..Jl�- YRm_ ....�..-_- �-
�.Q ❑�C'ertlied opy n hereby turn 'hid FIRE SPgINK ENERGY T44
�l Certil%i Lay is filed h the city' inspection division. ^ MISC - REFER TO ORD. J
Z Z 1C
PPBCaN V❑ N❑ V ❑ N❑
OCy CIS R'I'IP 1CA1 E OF EX EM If ION PROMs tKFKS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.c.
LU > COPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
d Y[:] N❑ Y [D N❑
D iThis sedirin nc,d nophc completed if the P,arut is for One TOTAL
2. hundred dollars(SION)c6less.)
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mm
it is issued.I shall net employ any person in any manner so as to
U become subject In the Workers'Compensation Laws of California.
BE.ED Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} 0 NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F-. ? emption,you should become subject to the Workeri Compensation APPLIANCE 4.00 PLAN CHECK
provisions of (he Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10=r-F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0)000C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the perforn.ance of(he 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
Lenders Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTF31C
I certify that I have read(his application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING
hrdinunms and state Daws relating to building Construction, and BOILER-COMPI3 H.P.or 100,0008.T.U.) 4.00
hereby authorim representatives of this city to enter upon the BOILER-COMP (Over TDU-OOOBTU)SEE FEESCH. MECHANICAL
above-menlioned property for inspection purpose•'.
(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
a lirlged'this permit. MECH.CONT. LIC.NO. MECH.
C OTA TOTAL Q�
Signature of Appicant/Ci5noractoV Date
INSPECTOR COPY