C7156 11
A@PLICANT,TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
n `UDINO TMS L Z-1 APPLICATION & PERMIT 7156
ADO. E55
2ZZ )L I CT- BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
AWNNAME QTY. ELECTRIC PERMIT FEE
t/. v. rr PHD.E 6 3 1 z
CONTRACTOR'SUTLETS-SWITCHES-RECEP 5.00/1.00
NAME ryl
LIC,rvo. Z LIGHTING FIXTURES 5.00/1.00
CONTRACTo s
ADDRESS PPLIANCES-RESIDENTIAL 4.00
I II
L PHONE JZ PANELS 5.00 /Nvll
K/ DATE OF APPLICATION
ARCHITECT SIGNS B.QQ PLAN CHECK FEE P.C.NO.
OR
NGINE
LIC.No. SIGNS TRANS. 3.00
AARCH OR DDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
-6 -71- Q ZIP EMP.METER OR POLE INS. 15.00 ) i-
APPLICANT S MOTORS SEE FEE SCH. ✓ ( (T f�
ADDR Ess
/SIC SERVICE CHANGE 10.00
o o LICI'NSED CON"f RACTORS DECLARATION z r'
G o u I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE .
tcom numcing with Section 7000)of Division 3 of the Rosiness amt Bgpy. ELECT. PLG. MECH.
wz 1'rofcssions Co ud my license is in full force and eft cI
Z O h -� License CP ss Lic.Number
Q [ Uatc_ Contractor
H N rJ
a DING PERMIT
c O�UER DECL RATION BUILORMATION
E a u, U INFORMATION
wu- y I hereby affirm that I am exempt from the Contractor's License MISC.- p REFER TO ORD
LL0 Law for the followingrcason.(Sec.703 L5,Business and Professions PERMIT ISSUANCE 6.00 /v A)LUATION $/FT.
� - 0 Cade:Any city or county which requiresa permit to construct,after,
QQ Q Q Improve,dernolish,or repair any Structure,prior to Its Issuance,also ELEC.CONTR. LIC.NQ LEC.
D R requires the applicant for such permit to file a signed statement that TE
OTAL /v/ PERMIT TO
A w m he is.licensed pursuant to the provisions of the Contractor's License
r z i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe V
a liusine.ss and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
the basis for the alleged exemption.Any violation of Sect ion 7031.5 STORIES. TYPE CONSTR.
a by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN& VENT-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
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
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 S0.FT.FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve.
cots are not intended or offered far sale.If,however,the building AS-EA.SYSTEM-11NC.40UTLETS 4.00
r improvement is sold within one year of completion, the owner- IGAS-EA.SYSTEM-OV ER 4 (EA.) 0 BUILDING USE
builder will have the burden of proving that he did not build or im- E IND CON PB Omer
prove I'or purpose nfsale.l. I STRIAL WASTE TER
IN . 20. 0 [jEl El 1:10 1,as owner of the property,am exclusively contracting with
licensed contractors 10 construct the project(Sec. 7044.Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ' ASSESSORS PARCEL NO.
and Professions Codc:'I'he Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts fursuch projects with u contractors)licensed pursumu to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.for this , WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPI'NSATION D17CLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate ofro real to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified "
copy thereof(Sec.3800,Labe.). S4.� S-
o
Policy No. Company
U ❑ Certified copy ishereby furnished. FIRESPRINK ENERGY T-24
Z Z XCertilic��1,,,y��.yis�flet/�.ih�Mthe� pity inspection division. M C.- REFER TO ORD.
Q APPlicunl-F/-,SI�F-Ft�Qpr w� 1 Y ❑ N❑ Y ❑ N❑
2to CEM IFFIiCA'rh od:I:XIiMrl'ION PROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU >_ COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
O (This sedisin need not be completed if the permit is fur one TOTAL Y❑ N❑ V❑ N❑
Z hundred dollars($1001 or less.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
IL P mil is issued,1 shall not employ any Person in any manner so as to
U become subject to the Workers'Compensation Laws of California
a Dafc ApplicantBUILDING
ALTER OR ADD TO MECH. 4.66
} to NOT ICH TO APPIJCAN'L` it,after making this Certificate of
Ex-emption,you should become subject to the Workers'Compensatmm APPLIANCE 4.00 9, PLAN_ CHECK
provisions of the Labor Code„you most forthwith comply with FEE lam'
U such provisions or this permit stim
eil be deemed revoked AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for XHAUST HOOD(WITH DUCT) 2.00
the purlormance of file work for which tills permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3097,Civ.C.).
Lindell,Name Lender01a HEATI NG UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lenders Address
I certify that I have read this zppheation and sate that the above VENTILATION FAN (SINGLE) 3.00
Infnnnution is correct, I agree to comply with all city and county - PLUMBING `
rquanc. and state laws relating to building construction, and BOILER-COMP(3 H.P.Dr 100,0008.T.U.) 4.00
�rereby authorize rcpresentativw of this city m emir upon file BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes. - J
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. f
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequenc of the PERMIT ISSUANCE 3.00
gra ^ oo-f"his pcnniL //j,,yrr��/ .MECH.CONT. LIC.N0. MECH:
(� �l�f� Z% TOTA. TOTAL �C
$ 10101 Ap di<:u I nl actor Uare C//�
INSPECTOR COPY