7059 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BO,LRING APPLICATION & PERMIT 7059
Bit LOIss
77j,4 /'U/)/N/J at. W'Q BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME
• ' fp y/1/ CA RR ULLoNE 7. i >-(t� OTV. ELECTRIC PERMIT FEE
PH
CONTERACTORs UTLETS-SWITCHES-RECEP 5.00/1.00
NA
LIC,NO. LIGHTING FIXTURES 5.00/1.00
CONTRACTOR PPLIANCES-RESIDENTIAL 4.00
ADDRESS
` PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.No. SIGNS TRANS. 3.00
ADDRRESS ENG. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP JTEMP.METER OR POLE INS. 15.00 p
APPLICANT MOTORS SEE FEE SCH. ..l
ADDRESS
D ac_
SERVICE CHANGE 10.00
Foo
LICENSED CONT RAC'IORS DECLARATION /1A5
a u u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
z "' (commencing with Section 70001 of Division 3 of the Business and
n BLDG. ELECT. PLG. MECH.
F N Z Professions Code,and Pry license is in full lute,mW effect. ❑ ❑ ❑ O
z o m - License Class Lic.Number
Q H. w Date Can tractor
a m EE �.. BUILDING PERMIT
E o u,O OWNER-BUILDER OECLARA'I']ON INFORMATION
w3 LL y I hereby affirm that I um exenrpl from the Contractor i License MISC.- REFER TO ORD
H u O j Law for the fullowing reu,son.(Sec.7031.5,Businessond Professions PERMIT ISSUANCE 6.00 VALUATION S/FT.
Code:Any city or county which requires a permit to construct,alter,
Q Q Q Improve,demolish,or repair any structure,Neture,prior In Its issuance,also ELEC.CONGER_ LIC. O. ELEC.
' w0 a requires'ti a applicant for such permit to file a signed slalement that TOTAL PERMIT TO
$ he is licensed pursuant to tire provisions of the Contractor's Liana �L(✓/y d/^Q
H z i [.use(Chapter 9(commencing with Section 70001of Division 3 of the
< Business and Professions Code)or that he is exempt therefrom unit QTY. PLUMBING PERMIT FEE
H. o (he basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
ic
ate _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not Prone than five hundred dollars(5500).):
Cl I,as owner of the proper(Y,or my employees with wages HIS BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and tire 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 docs not apply to an owner of
properly who builds or improves(hereon,and who docs such work FIXTURES-PER TRAP 4.00 So.FT FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve- - .
mems are not intended(ir offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or in provmmcnt is sold within one year of completion,the owner- GAS-EA.SYSTEM OVER 4(EA) 1.00 BUILDING USE
prove builder will have the burden of proving that he did not build or ice- RES IND CPB Omer
for Purpose of Sade.). INDUSTRIAL WASTE INTER. 20.00
O 1,as owner of the pwper(y,um exelasivcly co�lracling with ❑ ❑ ❑ ❑ ❑
licensed contract.,, to construe, 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 does not apply
to as owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts forsuch projects with u conlractonsl licensed pursuant to
the Contracmri License law. SEWERt-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I:un exenrpl under Sec ,B.&I'.C.fur flus WATERIHEATER W/VENT 4.00 °�
reason
Owncrp- Date WATER SYSTEM 4.06 ACC.DATE ACC,FILE NO.
WORK Ie RS'COMPEN'SA'IION OSCLnkA'fdoN WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent to self-inure. ZONING
or a cerldicale orworkers'Compensation Insurance,or a certified ENG.SITE NO.
enpy thereof(Sic.3800.I-ab.C.).
Policy be. Company
O ❑ Certified copy ishereby furnished. t. FIRESPRINK ENERGY T 24
Z Z ❑ Certified copy Is tiled with the city inspection division.
MISC.- `) REFER TO ORD.
� Applicant V ❑ IN E] V ❑ N❑
~ y PERMIT ISSUANCE 6.00 (a P_' FLOOD ZONE A.L.u.Cr
LU Cli k'fIFICATF,t1PIAijl(PfINS PROM WORKERS'
W �_ Ced of be co N INSURANCE the PLG.CON LIC.NO. PLG. Y❑ N❑ Y ❑ N❑
d (This Rolm, 10J nut be complete) if the permit is for one TOTAL
D Z hundred dollars(5100)or less,)
U O 1 certify (hal in the performance of tlla work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mil is issued, 1 shall not employ any person in any manner so as to
Ow become subject to The Workers'Compensation LLWS of California. BUILDING
Q. Dale Applicant ALTER OR ADD TO MECH. 4.00
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F Z emplion,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
C..) such provisions or this permit shall be leaned revoked. AIR HANDLING UNIT(TO 10MC.F.14) 3.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10SWGEM.) 5.00 SEISMIC FEE
I hereby aflinm that (here is a co witclimn lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance 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',Name
LH EATI NG U N IT(OVER 100,000 B.T.U.)T50
inder Address ELECTRIC
Icertify that l have read this application and xtate
olat the above VENTILATION FAN (SINGLE) 3.00
information is correct, 1 agree to comply will,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 authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTUI SEE FEE SCH. MECHANICAL
uhovrmenlioncd 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 permit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
/ 5 a ure of pplicant/ onhacIoor DAN,
INSPECTOR COPY