C7261 r ~APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
* s-
r q- 80DING PROJECT IDENTIFICATION PERMIT NUMBER
OUICDING' - RA /� / /�� ora APPLICATION & PERMIT Cl1
ADOR 5• C LA r I�1� L / /C BUILDING - ELECTRICAL-PLUMBING-MECHANICAL V
OW R'S O G 1 PLAN CHECK VALIDATION
/`I
NAME ` `♦ U CITY. ELECTRIC PERMIT FEE
A(fS5E.LL f TO4CE. LEwo,�E
-�' CONTRACTORS OUTLETS-SWITCHES
-RECEP 5.00/1.00
NAME
e[/ .. No. t. r LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'SPPLIANCES
-RESIDENTIAL 4.00
ADORE �(
ILLI-L- �Ar[t/� HONE ] PANELS 5.00 DATE OF APPLICATION
OH
WILLIAM E-AEQCN SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ON - 11
ENGINEER •R ON DI 4:.r� DEES;
uZ.NO. SIGNS TRANS. •3.00
ARCH.OR ENG. PERMIT VALIDATION
AODREss AtON RC ASSO
ATES- SPECIAL CIRCUIT 5.00
3180 NEwO
AIR "Di S•3• za, .Fill EMP.METER OR POLE INS. 15.00
' APPLICANTS RV.S3ELL LE WIS MOTORS SEE FEE SCH.
AOOness
7507 W LA TAACE' DR. CUAlq SERVICE CHANGE 10.00
00 LICENSIiD CON'I'RACfORS DECLARATION
u u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
aHi<m (commencing witlr Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH:
H h a, 11mfcssiuns Code,a y license ism full force an effect.
z o m- License Class_ Lic.Numb
ractor er I. z �, ❑ ❑ ❑
O_ Dale w Contj �
¢ m re JR A ! BUILDING PERMIT
m ¢w a ( OWNER-BUILDER UECLARA' INFORMATION
A Oar MISC.- REFER TO ORD
I hereby affirm that I am exempt from Ore Contractor,License VALUATION $/FT.
.. la
o ¢ w for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00
� -o, Code:Any city or county which requiresa permit to construct,alter,
rt a¢ 2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC. (go
� ¢ requires the applicant forsuch permit tri a signed statement that '- TOTAL PERMITTOCIC,V 1T
a m m he is licensed pursuant to theipr6isions of the Contractor's License
Hz >
Law(Chapter 9(commereingwith Section 7000)of Division 3 ofthe S�N6CC T•0.-y.Gy
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT -FEE
se F Qo the basis for the alleged exemption.Any violation o(Section 7031.5 STORIES TYPE CONSTR.
i
;m by zany applicant fora permit%objects the applicant toa civil penalty gLTER-DRAIN&VENT-WATER (EA.) ,/
of nut more[Iran Five hundeed'mAhms($500)): � S , A f-
• ❑ 1,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 stnclure is of
intended or offered for sale(Sec. 7144, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 -�-�
Code:The Contractor's License Law dos not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOH AREA TOTAL ACREAGE
+� himself or through his own employees,provided that such improve-
l` .cuts are not intended uroffered for sale.l f,however,the building GAS-EA.SYSTEM-l1NC.4OUTLETS 4.00 aef
or improvement is sold within one.year of completion,the owner- 746
GAS-EA.SYSTEM-OVER 4(EA.) 1,00 BUILDING USE
builder will have the burden of proving that he did not build or int- RES IND CON PB O neo
prove for purpose of sat,:.). INDUSTRIAL WASTE INTER. 20.00
❑ 1,as owner of the properly,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
1c'rived contractors to construct the project(Sec.7044,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 3 JI 7
contracts for such projects with a contmCtoes)licensed pursuant to
the Contractors License Law. SEWER-SANITARY-STORM EA.200ft/8-00 TRACT NO. PARCEL NO.
❑ lamcxemptunder Sce�,B.&P.C.f..IN, WATER HEATER W/VENT 4.00
Treasury 7s7C z
Owner Date WATER SYSTEM 4.00 PCC.DATE ACC,FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4-00 ♦e
1 hereby affirm that I have a eertificale of consent 10 set Ginsorc. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
I copy thereof(Sec.3800,LA.C.).
Policy No. "Company R aJ -' ¢.J�
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified c py is filed with11 'ty inspection division. MISC.- REFER TO ORD.
D.i Applicant Y [:] NE] Y [:] N❑
CC L4 CERTIFICAT11 ' :XEMI'TION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.0 C.
IU > COM F.NSATION INSURANCE PLG.CONTR. LIC,NO. PLG.
a.'0 This section need not be completed if the permit is for one TOTAL Y❑ IN E] Y ❑ N❑-
D Z hundred dollan'(S 100)or lcxv.)
U O 1 certify that in tom perfinm.nec of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any manner w as to
U become subject to the Worker;Compensation Laws of California. / 0=
W
Data Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} 0 Not o I'ICii 'f0 APPLICANI: If,afrmaking this Certificate of Ex-
? mnption,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=C.F.M.) 3.00
CONST RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10ACC.EM.) 5.00 SEISMIC FEE /33,o
-
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work far which this permit is issued(Sec. MICROFILM r'
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
1 certify Ihat I have read If,application and stale they the above VENTILATION FAN (SINGLE) 3.00
intornmlion is correct, I agree to comply will,oil city and coon ly 'PLUMBING
ordinances and state laws relating to building construction. and .BOILER-COMPI3 H.P.or100,000B.T.U.) 4.00
hereby authorize representatives of this city ro enter upon the gO1LER-COMP(Over 100,000 BTU)SEE FEE SCM. 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 PERMIT ISSUANCE 3.00 CONST.TAX
may.,in any way accrue against said City in consequence of the
granting of this pentyl L MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL 9,20
1�- Signature Applic otos to Date '
INSPECTOR COPY