7057 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATION PERMIT NUMBER
ADLL ESS APPLICATION & PERMIT 7057
aoORE55
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME
_ ,/ QTY. ELECTRIC PERMIT FEE
vnorvE
X G.NTRAcrons UTLETS-SWITCHES
-RECEP 5.00/1.00
NAME
' Llc.No Lif< ILIGHTING FIXTURES 5.00/1.00
DREACiOR'S
AD
CONTRA SAtJ"jtxS' APPLIANCES-RESIDENTIAL 4.00
BONE Cl�tl_oi4ynPANELS 5.00 _ DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.No. SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
An ESS
r$
Anon
MOTORS SEE FEE SCH.
APP IC
SERVICE CHANGE 10.00
o o LICENSED CONTRACTORS DECLARATION
¢ v U 1 hereby affirm that I am licensed under provisions of Ch.plc,9 ISSUANCE DATE
odi (commencing With Section 7000)of Division 3 of the Rusme,s and B DG. ELECT. PLG. MECH.
F D z I'ral'e"ions Co'dcy'd my lice a is in full for r and efl'eyyt�.�r
oi �)a License Classy�p_ Lic.Nmnher Urle `ice � ❑�
m H w Dale-/-� -J-�- Conn Facto,
a m BUILDING PERMIT
¢ S, w OWNER-BUILDER DECLARA-1'ION INFORMATION
X
tL r I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
LL o a Law for the following reason.(Sec.7031.5,Businessund Professions PERMIT ISSUANCE V DATION 3/FT.
-' Code Any city Or county whichre9uiresapermittocunstrucLalter. 6.00
SE rt ¢ 2O improve,demolish,ur repair any structdre,print to its xsuance,also ELEC.CONTH. LIC.NO. ELEC.
¢ requires the applicant for such permit to file a signed statement that TOTAL - q TO
o. w m¢ he is licensed pursuant to the provisions of the Contractor's License
rzi
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r w IIIc basis,(.,the alleged exemption.Any violation of Section 7031.5 ST TYPE CONSTR.
a3 _ by a my applicant fora permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
I
odnnl more than five hundred dollars($500).):
0.,I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their rule compensation,will do the work,and the structure is not
intended oi•offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
pnq)erty Who build,or Improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 SQ FT.FLOOR AREA TOTALACREAGE
himself or through his own eniployeus,provided that such ier,rove-
mesus are not;mended or offer"]list sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
.,'improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4(EA.) 100 BUILDING USE
buiateewill have the burden of proving that Ile did not build or int . . .
ES IND CON PB Other
Prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 El ❑ El 1:1❑ I,as owner of the property,:un exclusively contracting With
Jicenscd contractors to construct the protect(Seo.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Prulessions Codof'I'he Conlraclur's License Law does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contmcmr(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 ..TRACT NO. PARCEL NO.
t$O�I am exempt under Sea ,R.&P.C.for this WATER HEATER W/VENT4.00
reason _
Own,, Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKI'RS'COMPENSA IION DECLARATION WATER TREATING EQUIP. 4.00
`I hereby affirm that I have a certificate Ofsoporpt to self-insum' ZONING ENG.SITE N0:
or a certificate of Workers'Compensation Insurance,o certified
copy mere (_�s,_eJ}',�3 00,Lan col. 3 G3cOA
I'o0 N,Died lumpany l
Q D Certified copy�Ls hereby furnished. FIRE,PRINK ENERGY T 2
z� W_CertiOed c PY is filed wit .the ci�inspecliun division. MISC.- REFER TO ORD.
O Applicant Y❑ No Y ❑ NE]
Clik'f -ICA'I'Ii OP IiXEMI'I']ON FROM WORKERS'
PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.00. -
W - COMPFNSWION INSURANCI: PLG.CONTR. LIC.N0. PLG.
CL CL z YI'his section Cecil not be completed if the permit is for one TOTAL Y E] N❑ Y E] NE]
hundred dull,,(S 100)or less-)
L) O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mil is issued.I,hall not employ any person in any manner so as to
U bec.Inc subject to the Work,,,'(:....1pensatim Laws Of California.
LID Late Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} rn NO'IICIi"IO API'LICAN'E. I(,a0cr making this Certificate ificotc of lix-
F ? entption,you should become subject to The Worker;Compensation APPLIANCE 4.00 PLAN CHECK
provisions Of the Labor Code, you most forthwith comply with FEE
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10jM0C.F.NL) 3.00
I.l
CONS'I'k UCTION LENDING AGENCY AIR HANDLING UNIT(OVER l0,000QF.M) 5.00 SEISMIC FEE
I hereby affirm that there isconstruction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the purf.rmenec of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lend,r's Name HEATINGUNIT(OVER 100,000 B.T.U.)7.50
Lender;Address ELECTRIC
,a I cul lify That l have read this application and state mat the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and stale laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over lOg000 BTU)SEE FEE SCH. MECHANICAL
above mentioned properly 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
play in any way accrue against said City in consequence of the
granting fthiSpermiLMECH.CONT. LIG NO. MECH.
TOTAL TOTAL
S' ature ot'ApplumpoJe6puractor Dale
INSPECTOR COPY