7225 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATION PERMIT NUMBER
9y5
BUILDING APPLICATION & PERMIT 725
ADDRESS G-,SO/-I B2
UILDING - ELECTRICAL-PLUMBING-MECHANICAL � '
OWNER'S PLAN CHECK VALIDATION
NAME TY. ELECTRIC PERMIT FEE
ONE ass�
a �
CONTRACTOR'S '
. DADe �I [OUTLETS-SWITCHES-RECEP 5.00/1.00
sea Nn�Qyy�j LIGHTING FIXTURES 5.00/1.00
CONTRACTORS ^fQ NES TUU7`
ADDRESS 57-
. PPLIANCES-RESIDENTIAL 4.00
' C
♦� Q r T C�- PRONE q/ 9-o'�( PANELS 5.00 DATE OF APPLICATION
ARCRITECT
OR SIGNS 6.00 PLAN CHECK FEE P.C.NO.
`.
ENGINEER
f sec.No. SIGNS TRANS. 3.00
too Ess eeG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
ADDRESS MOTORS SEE FEE SCH.
_ AOREss 1121y,< SERVICE CHANGE 10.00
o o LICENSED CONTRACTORS DECLARATION
a U U 1 hereby aftirm that 1 am licensed under provisions of Chapter 9 ` ISSUANCE DATE
dG a w ( otmne tung..i,p�SecUmt 7000)of U v"o%3 of tireBusiness aqd _-BLDG. ELECT. PLG. MECH.
rofesson CDit u�rid ny�Imensc I. m(sell format (¢�,�"- + 'e" "'•g ❑ ❑ O
- O Z a 1 nnu CJyss_[_-�;1,(L Lic Number v y' r
R H w Date-D-(i-�-Contractor 1
x rc a OWNER-BUILDER DET
CLARAION BUILDING PERMIT
o a " MISC.- REFER TO ORD INFORMATION
3 LL r 1 hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
F LL o a, Law for the following reason.(Sec.7031.5.Busincssand Professions PERMIT ISSUANCE 6.00
m0 Code:Any city or county which requires a permit to construct,alter,
re Q Q p Improve,demolish,Rh,or repair any structure,prior t0 its issuance.also ELEC.CONTR. LIC.NO. ELEC.
,< DLL reg sires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
n ce m i he is licascd pursuant to the provisions of the Conlr,¢lor's License /a//IV,�/
z Law(Cbapter 9(ttnnmencing with Section 7000)of Division 3 of lire
i o Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
,- $ the basis for the alleged exemption.Any violation of Section 7031.5 STORI S TYPE CONSTR.
u ,
by any applicant for a permit subjects tire applicant to a civil penalty
of not more(Iran five hundred dollars(S500).): ALTER-DRAIN&VENT-WATER (EA.) 4.00
O 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 structure is not
intended or offered for sale(Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code"fhe Contractor's License Law does riot apply to an owner of
property who builds or improves themaq and who does such work FIXTURES-PER TRAP 4:00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mems arc not intended or offered for Sale.IL however.the budding GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 100 BUILDING USE
builder will have the burden of proving that he did not build or im- . RES IND CON PB Olner
Pr
far purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ 0 ❑
❑ I,is
owner of the properly,am exclusively contracting with
licensed co
nnractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
sort P,olcss a ns Code:The Contractor's License Law does not apply
to mi owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts l'oursuch ctoCsLceneLwithacontractor(sl licensed pursuant to SEWER-SANITARY-STORM EAo2.00ft/8.00 --,TRACT NO. PARCEL NO..�
the Contractor's License Law.
❑ 1 ant exempt under Sec. ,B.&KC.for this WATER HEATER W/VENT 4.00
reason
Owner [)ate WATER SYSTEM 4,00 ACC.OATE ACC.FILE No.
H
WORK IiRS'COMI'IiNSA'I'[ON DECLARATION WATER TREATING EQUIP. �j 4.00
I Iteri.(iy affirm that I have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance.or a certified I
. .copy the}cot(Se3 00,Leh Ca .-• 1._ _ i.."_ 'Y
Policy N�' T f ompanr -RITFR'P?rg E M- 1
Q ❑ C rfi icd 'Op by f sir N. :• Ay FIFE SPRINK ENERGY T 24 'I
fYCe rilic fled It Ibe ity Ins tion drvivon
z p
Applicant_ • MISC.- REFER TO ORD. y O N F0 Y ❑ IN
CCT CERI'IPICATli 017 EXEMPTION FROM WORKERS' PERMIT ISSUANCE �� 6.00 FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. pj;p, �•f
,? Z (This section need not he completed if the permit is for one r TOTAL Y.� N� Y E] NJ
hundred dolllu,t S 100)or less.)
U O I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- it is I...ed;I shall not employ any person in any mainerro as to
O ° become subject to the Workers Compensation Laws of California. BUILDING
a Dam Applicant ALTER OR ADD TO MECH. 4.00
} to
NOTICE'I'O AVPLICANT: IL after making this Certificate of 1>x-
F Z Imprint,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK-,,- ,mss•.
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 1000011F.M.) 3.00
CONSTRUCTION LENDING AGENCY. AIR HANDLING UNIT(OVER 10=C.EM.) 5.00 SEISMIC FEE
I hereby affirm that thuic is u construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00 -
the performance of the work for which this permit is issued(Sec. ,I MICROFILM
3097.Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00 H
Lender's Name H EATING UN IT(OV ER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that I have read this applimriou and slate That the above4B(OILER-OC)MP(3H.P.orlOO,000B.T.U.)
ENTILATION FAN (SINGLE) 3.00
iroulorrion is correct. Degree to comply with all city and county PLUMBING
i ordinances and state IawsRclating ro building construction, and 4.00hereby authorze representatives of Otis city toenn theOILER-COMP (Over 100,000BTU)SEE FEESCH. MECHANICALabove-mentioned property 1or inspection purposes(We) agree to save, indemnify and keep harmless the City ofISC.- 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
gra m of this pe MECH.CONT. LIC.NO. MECH.
�O �S�' ?,5 14
INSPECTOR
7 E/7r)NG a7NI/Q TOTAL 700 TOTAL �)
Signage o Applicant Contras or Date
INSPECTOR COPY