C7202 II,A P ICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY.
y BUILDING PROJECT I DENTI FI CATION PERMIT NUMBER
OnJIL.INGAPPLICATION & PERMIT
ADDRESS BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 7202
✓ OWNER
NAMEI \~'�9 \ � PLAN CHECK L/IRA-r7�I�ON
d' OTY. ELECTRIC PERMIT FEEto a
CONTRACTOR S
NAME ^ OUTLETS-SWITCHES-RECEP 5.00/1.00
G LIGHTING FIXTURES 5.00/1.00
CONTRACTOR`sA\cz�r N APPLIANCES-RESIDENTIAL 4.00
ADDRESS
-A, T�\-� - / J\1�HONE� G PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO,
OR
ENGINEER
' sec.No. 'SIGNS TRANS. 3.00
ADD ESS cmc. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
1 ZIP EMP.METER OR POLE INS. 15.00
APPLICANT 7441 IfMOTORS SEE FEE SCH.
ADDRESS
s - SERVICE CHANGE 10.00
w¢ i
F o o - LICE, CONT RACI'ORS DECL A'f10N
NSIiU
Q U U I hereby aflinn that I am licensed under provisions of Chaplcr 9 ISSUANCE GATE
ham (commencing with Section 7000)of Division 3 of the Business and BALD ELECT. PLG. MECH.
F m z Professions Code,and my license is in full force and effect. I ❑ ❑ ❑
z o m - License Class Lic.Number
Q r w Dom Contmewr
¢ aBUILDING PERMIT -
¢ ¢w OWNIiR-BUILDER DECLARATION - INFORMATION
w3 a y I hereby affirm that I ant exempt from tire Contractoh License MISC.- REFER TO ORD
H u 0 4 Law H r the following reason.(Sec.7031.5,Businessand Professions 'PERMIT ISSUANCE 6.00 �VA•wnnON.+s SIFT.
� mi� Code Any city or county which requiresa permit toconstruct,alter,
¢ ir sr 0 improve,demolish,or repair any structure,prior to its issuance.also ELEC.CONTE. LIC.NO ELEC,
a w0 LL requires the applicant for such permit to file a signed statement that TOTAL `````` ������ yypyypERMIT TO
m he is licensed pursuant to the provisions of the Cmuractor'S License S/n/
r z a
Law(Clutter 9(commcncing with Section 7000)of Division 3 of the
4 o Business and Professions Code)or that Ile is exempt lherefmm unit OTY. PLUMBING PERMIT FEE
¢ F p the Ii sns fur the alleged exemption.Any violation of Seetion703L5 STORIES TYPE CC,O//NSTuIR,,
1 wa13m byan4YLapplicant fora permit subjects the applicant toacivil penalty ALTER-DRAIN& VENT-WATER (EA.) 4.00 16 , i"l
! of not Ib roc than five hundred dollars(8500)_):
❑ I s owner of the property,ser my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OC .GROUP RES.UNITS
their soleplcompensation,will Jo the work,and the sweture is not {�C
intended Ar offered for sale (Sec. 7044, Rosiness and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 '` j
Code:Tha!Contmctor'S License Law does not apply to an owner of
property who bolds or improves(hereon,and who does such work FIXTURES-PER TRAP 4.00 �g E>��oggAREA TOTALACREAGE
himself or through his own employees,provided that such intprovc T /
moots are not intended or offered for sale.IC however,the building GAS EA.SYSTEM-11NC.40UTLETS 4.00 /
r
provemmwEA.SYSTEM-OVER 4(EA.)
ent is sold within one year of completion,the owner- EA.-
s bityper will have the burden of proving that he did not build or int-
1.00 BUILDING USE
( pr efor purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 .QES I❑ ❑N ED 11 d.1:1 enc' ❑ 1,as owner of tire am exclusively property.aexclusively contracting with �f
licensed 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;in owner of property who builds in improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) ' 1.00
sun tracts lit.such projects with a coutractoos)licensed pursuant to
I the Cont tor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
u tat xenmd mite Sec. ,B.&P.C.f r i. WATER HEATER W/VENT 4.00
He (r
D
Owner ate WATER SYSTEM A 4.00 ACG GATE ACG FILE NO.
ORKERS'COMPENSAIION DECI.ARATION WATER TREATING EQUIP.;, 4.00
I hereby affirm thud 1 have a cretificum of cnnsenl Rt self-inert. ` ZONING ENG.SITE NO.
+ or a certificate of Workers Compensation Insurance,or a certified
copy thereof(See3800,Lab.C.).
Policy No. Company
Q ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
z Z ❑ Certified copy is filed with Ore city inspection division. MISC.- REFER TO ORD.
'O Applicant l Y E] IN E] Y ❑ N❑
CC y_ CER'I'I FICATE OF E.XIiNIP1 ION FROM WORK ERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
Lu COMPRNSA'1'ION INSURANCE' PLG.CONTE. LIC.NO. PLG.
d O Il'his section need not be completed if Inc permit is for one TOTAL Y❑ N❑ Y ❑ IN
Z hundred dollars IS 100)or Tess-)
U OI certify that in the performance of the work for which this per, CITYMECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any person in any manner so as to Jj
O w become subject to lire Workers'Compensmion laws of California. BUILDING �O `
y Date Appli°ant - ALTER OR ADD TO MECH. 4.00
} NOl'ICE TO APPLICAN 1': If,after making this Certificate of 1;s-
F_ emption,you should become subject to the Workers'Congtcnsulion APPLIANCE 4.00 PLAN CHECK j
.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
t CONS I'RUCI'ION LENDING AGENCY AIR HANDLING UNIT(OVER 10)DOOC.F.M.) 5.00 SEISMIC FEE / 7S
1 hereby uffion that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the pcdormance of fire work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lrnde;s Namy HEATING UNIT(OVER 100,000 B.T.U.P.50
tendon Address ELECTRIC
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct I agree to comply with all city aad county PLUMBING
ordinances and staie_Iuwl relating to building construction, and BOILER-COW(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU(SEE FEE SCH. MECHANICAL
(We) agree or 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 't /h
may in any way accrue against said City in consequence of the
gorrunli liropermil. MECH.CONT. LIC.NO. MECH. / a/�
/ . .� .( � r TOTAL TOTAL 07
Ignuture of Appheard Contractor Dal
I INSPECTOR COPY