7143 Y ; <
APPLICANT TO-FILL IN INFORMATION WITHIN REDLINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
t 7143
ADOR ess
BUILDING - ELECTRICAL-PLUMBING -MECHANICAL
WN` OER'S - PLAN CHECK VALIDATION
NAME TY. ELECTRIC PERMIT FEE
CphDj,OUNTDy
r "s
NAME UTLETS-SWITCHES-RECEP 5.00/1.00
NAME •I
LN_ LIGHTING FIXTURES 5.00/1.00
cONTR o ,s PPLIANCES-RESIDENTIAL 4.00
ADoaE s
pH0 E PANELS 5.00 DATE OF APPLICATION
ORCHI EC SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.No. SIGNS TRANS. 3.00
nooeess ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP. METER OR POLE INS. 15.00
AODmDH rss
APPLICANT MOTORS SEE FEE SCH.
E55
SERVICE CHANGE 10.00
0¢ i
,<
02 LICENSED CONTRACTORS DECLARATION J r
r
ou 1 hereby affirm that I am licensed under provisions of-Chapter`) ISSUANCE DATE
t" H 3 w Iconunencing with Scclion]000)of Division 3 Of the Business and BLDG. ELECT. PLG. MECH,
r, r w i Professions Code,and my license is in full fore f t. ❑ ❑ ❑ ❑
Licrave Cl.s Li,
.Number
JO w Dulc-}-� r Co n tumor
BUILDING PERMIT
x
(¢ ¢ w a Ne BUILDER DECLn Rr\l'1 INFORMATION
dos " MISC.- REFER TO ORD
w 3 1 hereby affirm that I am exempt tions the Contractors License
U- VALUATION $/FT.
F u 0 a Law I'm the following reason. 7031.5.Business and Professions PERMIT ISSUANCE 6.00
F � 0Cotte:Any city orcomlty whichrequiresapermil toCmnstr¢Laltrr, ELEC.CONTR. LIG NQ
se U, a G improve,demolish-or repair any structure prior to Its issuance,also ELEC.
- 0, requires the applicant fin such Permit to file a signed statement that TOTAL PERMIT TO
u w m he is licensed pursuant to the provisions of the Contractor's License
LU z¢ Law(Chapter 9(commeicing witliSlembou 7000)of Division 3olthe
Business and Professions Code)or dal he k esempt therefrom and CITY. PLUMBING PERMIT FEE
M I o the basis for the allcgcd exemption.Any vidaticui Df Se,lim-7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects Ore applicant ton civil penalty
of not more than rive hundred dnlmrs(SS001.): ALTER-DRAIN&VENT-WATER (EA.) 4.00
❑ h uz owner of the properly,m 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 nal
�. intended or offered for sale(Sec 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor i 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 SD.FT.FLOOR AREA TOTALACREAGE
• himself or through his own employees,provided that such imGAS-EA.SYSTEM-1 INCA OUTLETS 4.00
Pravc-
mms are not intended or offered for sale.IL however, uildingr,the building
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not M1uiIJ or int- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIALWASTE INTER: 20.00 ❑ ❑ ❑ E:] ❑
❑ I,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:*1 lie Contractor's License Law does not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contracomms)licensed pursuant to
Ole Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ l am exempt un der See-.R.&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4,00 ACC.DATE ACC.FILE NO.
-
WORK IiRS'COntPISNSnION DECLA ItnTION WATER TREATING EQUIP. 4.00
I hereby affirm that 1 have a Certificate of eonsrnl to self-insure, ZONING ENG.SITE NO.
or a certificate of Wor
kers' om persa n n ran ,Or a certifi
V1Wf.l.
)
O y furnished- FIRESPRINK' ENEROYTQ4-
zp nPOlid viyl 'IY ecMISC.- REFER TO ORD, v N Y N. 6 ❑PERMIT ISSUANCE 6.00 FLOOD ZONEA.L.U.C.
d it TON PROM WORKERS'W > ATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y❑ N❑ Y E] N❑
� z 1'fhls section red not be completed if the peril is for one IOTA
U O huudmddolla Ls(S100)orlcss.) IF
1 certify that lin the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- nil is issued, l shall nor employ any person in any manner s.ns to
U become subject to the Workers'Compensation Laws f California.
LU D re Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
m NO110E TO APPLICANT: If,after making this Certificate of Ex-
�'_ F Z emotion,you should become Subject to rhe Workeri Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the labor Code, you must forthwith comply with FEE
such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
'#
CONS'fRUC'I'ION LENDING AGENCY AIR HANDLING UNIT(OVER I0,00011F.M.) 5.00 .SEISMIC FEE
I hereby-aflinn Oiu( rham is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work I'nr which this permit is issued(Sec. - MICROFILM
3077,Civ CA 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
I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 3.00
• information is correct. I agree to comply with all city and county (3 H.P.or 100,0006.T.U.) 4.00 PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP
hereby authorize representatives of (his city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEESCH. MECHANICAL
above-mentioned properly for inspection purposes.
.a- (we) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, casts and expenses which CONST.TAX
may in any way aceta gains[ said City in con,ypucnce of the PERMIT ISSUANCE 3.00
g ng of this permi. /Y, .CONT. LIC.NO. MECH.
An( V1� TOTAL TOTAL IQ'
SvdverrNpp icon -on[ractor Uat
. INSPECTOR COPY - -,