7137 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
-YC- aUILDING APPLICATION & PERMIT
ADDRESS �� ^n
3 r
S SAN LFAMIO, 0 "S BUILDING - ELECTRICAL-PLUMBING -MECHANICAL
IL_
OwNER'S PLAN CHECK VALIDATION
NnmE f QTY. ELECTRIC PERMIT FEE
DU rCT PHONE
NorMEancTOHs UTLETS-SWITCHES-RECEP 5.00/1.00
,qO1'N _':;e0QA1Lc.ND 00,5 LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00
/ ADDRESS V o
1 L ONE a��O�� PANELS. 5.00 DATE OF APPLICATION
ARCHITECTSIGNS 6.00 PLAN CHECK FEE P,C.NO.
on
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADORESS R ENO. SPECIAL CIRCUIT 5100 PERMIT VALIDATION
ZIP FEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00 ��
0 LICENSED CON'IRAM ORS DECLARATION a-',
ao u 1 hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
N z"' (commencing with Section 7000)of Division 3 of the Business and Q a BLDG. ELECT. PLG. MECH.
r m i 1'rol'essions Codc - nu is N full fur �un e0:e' ❑ ❑ ❑
z o w Liccnsc Class_syn ¢ I,ic.Number ful
2 m R G Date_J�2IJ.7-�Conlractor qC&I
r s ) BUILDING PERMIT it
¢ tr: IF u OWNER-BUILDER DECLARA'rION INFORMATION
Aoa MISC.- REFER TO ORD
w 3 LL r 1 hereby a117rm (hut I an exempt from the Commetor's License VALUATION
F w o¢ Law for tin following reason.(Sec.703 L5,Businessand Professions PERMIT ISSUANCE 6.00
in Code:Any city or counly which requires a perinit to constr ct.alter,'
2 improve,demolish,or repair any stricture,prior to its issuance,also CLEC CONTR. LIC.NO. ELEC. -
O c requires the applicant for such permit to file a signed statement that TOTAL PER"(7 TO
w m" he is licensed pursuant to the provisions of the Contractor's License _ �[
rz >
Law(Chapter 9(commenciog with Section 7000)of Division 3 ofthe
0 Business and Professions Cade)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ F o the basis for the alleged exemption.Any violation of Section 7031.$ STORIES TYPE CONSTR.
03 °1 by any applicant or a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not mare than five hundred dollars(55000.):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 oee.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,GOND. 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 So,FT FLOOR AREA TOTAL ACREAGE
himnscll'or through his own employees,provided that such im Prove.
nmrts are not intended or offered ter sale,11,however,the building GAS-EA.SVSTEM-I INC.4 OUTLETS 4.00
Or improvement Is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 (EA.) 100 BUILDING USE
builder will have tire . . .
e burden of proving that he did not build or im- RES IND CON PB amer
prove lb,purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
Cl 1,as owner of the property,um exclusively contracting Willi ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:'I'he Contractor'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
ommcts for such projects with it comracloos)licensed pursuant to
the Contractors License Law, SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO,
❑ I xn.exempt ardor See. ,B.&RC.for this WATER HEATER W/VENT 4.00
uson
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMN'NSA1 ON DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self insure.
a cell icme a Worker',
orker Compensation Insummee,or a certified ZONING ENG.SITE N0.
copy thereof ISec.3800,Lab.CA
Policy No. Company
❑ Certified c'o y is hertb}'furnished. FIRE SPRINK ENERGY T24
��jj''''Cvr fe,d e sy ix fled ith the ' inspection division. MISC.- REFER TO ORD.
z Alfpltcull- Y ❑ N❑ Y ❑ N❑
OC N CERTIFICATE OIr IiXIiMP' ON FROM WORRIiRS• PERMIT ISSUANCE - 6.00 FLOOD ZONE A.L.u.C.
I UJ D COMPENSATION INSURANCE. PLG.CONTR. LIC.NO. PLG.
CL 0 (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
Z) z hundred dollarsf$100)or less.)
LUV I-O 1 certify that in Hie performance of tire person or any or which thisaper. QTY. y MECHANICAL PERMIT FEE FEE SUMMARY
mil is issued,I shall ,of employ
U become subject to the Workers'Compensation Lows of California,
°1. Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
0
} N NOTICE TO APPLICANT': If,after making this Certificate of Ex-
� Z en,ption,you should beconu.,subject to the Worker:Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you nwst forthwith comply with FEE
U suet,provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER IO,ODOOEM.) 5.00 SEISMIC FEE
I hereby aftion that Were is a construction lending agency lir EXHAUST HOOD(WITH DUCT) 2.00
the periormance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
1 certify that I have read this application and state that the above VENT( ATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP I3 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 BTU)SEE FEE SCH. MECHANICAL 7 6kd
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep handless (he 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 tire
�1 ng of this permit MECH.CONT. LIC.NO. MECH.
� �_a Ss TOTAL W TOTAL
Signature of A pplie Contractor Date O
INSPECTOR COPY