7134 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS /^v
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
O L7-
713
Ow R'S PLAN CHECK VALIDATION
QTY. ELECTRIC PERMIT FEE
ON
• Q�r EIONE
TRAC DRs OUTLETS-SWITCHES-RECEP 5.00/1.00
NA /
.[e TGJi ue.No. ` LIGHTING FIXTURES 5.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
ADDREss (
�� � f7`e',((,1.6 vHON gyp` PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 600 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
, uc.No. SIGNS TRANS. 3.00
noo ess ENG' SPECIAL CIRCUIT 5.0Q PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANT'S
ADDREss MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
woo LICENSED CONTRACTORS DECLARATION
rt v U I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
Vs G m (Conmtencing with Seel ion 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
Vs N z 1'ro fessions Cody un nl license is in full force and 0 ^ ❑
Licmuc Class S_-. _�Lis.Nmnbcr IyXYI
Date,. �� Contractor
BUILDING PERMIT
¢,¢ w a OWNER-BUILDER DECLARATION INFORMATION
O ° MISC.- REFER TO ORO
w 3 aa_ r I hereby affirm that I am exempt from the Contractor's License
st Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE VALUATION S/FT.
F 1 o
Code:Any city ur County which requires a permit to construct,alter, 6.00
¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIG NO. ELEC.
G¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
'6 w w" he is licensed pursuant to the provisions of the Contractor's License
i Law(Chapter 9(commeucingwith Section 7000)of-Divisiou3ofthe �L�G
t i o Rosiness and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ F the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant lot a permit subjects the applicant o a civil penally ALTER-DRAIN& VENT-WATER (EA.) 4,00
of not more than five hundred dollars(8500).):
❑ I,as owner of the property,or myemployees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the S INCtllre is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does notapply to an owner of
properly who builds or improves thereon.and who does such work FIXTURES-PER TRAP 4.00 /4 so.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such Reproof-
mcntsare not intended oroffered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of-proving that he did not build or im- RES IND CON Pe On.,
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. ' 20.00
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
" licensed L-Invractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Coda.The Contractor's License Law docs 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 contonoms)licensed pursuant to
ore Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ l am exempt under Sec.-.BAP.C.for Ibis WATER HEATER W/VENT 4.00
re,"m
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to sell'-invuee, ZONING
-/ or a certificate of Worked Compensation Insurance,or a cerlified ENG.SITE NO.
__7L
T copy thereof(Sec.3800,1,ah.G.I
Policy Ne. Compwry
, 0 ❑ Certified[ shertb�yvml)' ed. FIRE SPRINK ENERGY T 24
Z Z Certifi op iI Ed/witlt't it city inspection division.
MISC.- REFER TO ORD.
a O pplir. /n Y ❑ N❑ Y ❑ N❑
' ~ N � PERMITIISSUANCE 6.00 / FLooD zoNE A.L.u.c.
> RT} CA 'OP IiXh:1PTl0,' ROh1 WORKERS' - F' -
_ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. tnI V N V N
EL O 1'1111, section need not be completed if the permit is for one TOTAL a02 ❑ ❑ ❑ ❑
::) 2 hundred dollars(S100)or less
U O 1 reality that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F n.it is issued, I shall not employ any person in any manner so as to
U hecorne subject to the Workers'Compensation Laws of Chili ura.
WIAtc Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
Q.} to NOTICE TO APPLICANT'. If,after making this Certificate of Ex-
♦- Z option,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
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
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction leading agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this pernrit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
LenName
dcr's Nameder's NHEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Ur-
L,o
I certify that I have read this application and state flat the above VENTILATION FAN (SINGLE) 3.00 db
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 100,000 B.T.U.) 4.00 ^C hereby authorize representatives of this city to enter upon Ilie
above-mentioned property for inspection purposes. BOILER-COMP (Over 100.000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnitf�yy, and ISSeep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities, 't I meet Yfosls and expenses which CONST.TAX
may in any yr true ai 1 sa' Lhy in consequence of the PERMIT ISSUANCE 3.00
granting of fi �iL MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
ignatur, 1 Ii p1/Qmtracl r/ Daleli nllCnnlracl r/ Dale
INSPECTOR COPY