C7200 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BDILDING PROJECT lDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS BUILDING -ELECTRICAL-PLUMBING -MECHANICAL` 1 Y O
I-0100 T' f R
OWNER'S r PLAN CHECK VALIDATIO ti•
NAME _ i1 QTY. ELECTRIC PERMIT FEE
CCL AItQ\.. V EEONE O�
,AVE CONTRACTORS OUTLETS-SWITCHES-RECEP 5.00/1.00
NAME
(_ ayv\ uc.rvo, •;Cil^ S• LIGHTING FIXTURES 5.00/1.00 ,I
CNTRAC
AODRESS ORs PPLIANCES-RESIDENTIAL 4.00
IJ yr . wVO � FHONE k PANELS 5.00 DATE OF APPLICATION
j ARCHITECT SIGNS 6,06 PLAN CHECK FEE P.C.NO.
1
ENGINEER (2rN5L54L e-AS�pC n
LIG NO. it Z. SIGNS TRANS. 3.00 p
I ARCH.OR ENG. PERMIT VALIDATION
ADDRESS _ .��, SPECIAL CIRCUIT '5.00
� IP �ta� EMP.METER OR POLE INS. 15.00
1 A
ADDRESS
S MOTORS SEE FEE SCH.
. I
I V SERVICE CHANGE 10.00
E,o o LICENSED CON"f RACfORS DECLARATION
¢ o 0' 1 hereby affirm that I am licensed undm
mile,pvisin o of Chapter 9 ISSUANCE DATE
wa m (commencing with Section 7000)of Division 3 of the business and BLDG! ELECT. PLG. MECH.
0 m z Professions Co. ny4 d mY license is in full fuo:cyld.efGm� ❑ ❑ ❑
z a m — License Class 6 Lie.w is Number 1`9 1 �S
o w Date ']t t,�•/` Contractor
a Y f - BUILDING PERMIT
¢'¢ ¢ ¢ OWNER-BUILDER DECLARATION
E d MISC.- REFER TO ORD INFORMATION
w3 1- 1 hereby of firm that I am exempt from the Contractor's License
Ho_ Law for the following reason. 7031.5,Busineisand Professions PERMIT ISSUANCE 6W VALUATION E/FT.
Code:Any city or county which requiresa permit to construct'alleq 78 q.q�
. 40 improve,demolish,or repair any structure,prior io its issuance,also ELEC.CONTE, LIC.NO. ELEC. /
E
D,
requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
d w m he is licensed pursuant to the provisions of the Contractor's License /
H z¢
Law(Chapter 9(commencing with Section 7000)of Division 3 ethic, / CN9n/7 / OV.?
Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
rel the basis for the alleged exemption.Any violation ofSection7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant loacivil penalty ALTER-DRAIN& VENT-WATER (EA.) 4.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their side 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:The Contractor's License Law does not apply to an owner of
property who builds or improves themon,and who doesauch work FIXTURES-PER TRAP 4.00 SG.FT.FLOOR AREA TOTALACREAGE
himself are throughhisown emred fars,provided ever,such improve- GAS-EA.SYSTEM-I 4,00
cots are oat decoded or offend for sale.IL ed that s the building
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 it. RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER.w 20.00 El El El ❑ 1:11 ❑ I,as owner of the pro perry',am exclusively contracting with
licensed contractors to construct the Rroject(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 an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts for such projects with a contractorts)licensed pursuant to
the Contract.,',License Law. - SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec.—,IT&P.C.for this WATER HEATER W/VENT . 4.00
p_ reason -
f Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKIi RS'COMPIiNSAI ION DECLARATION WATER TREATING EQUIP. 4.00
1 1 hen,by affirm that 1 have a ecrtilicate dconwnt t.sell_inane, - _ ZONING ENG.SITE NO.
or a certificate of Workeri Compensation Insuram:a or a certified
copy thercuf(Sec.3800,Lab.C.L
PnBcyNr. 1 Compan JC Lon-Loot RU,Z14-•1-011
O O Certifiedcopyisberebyfielo,hed. -1 FIRESPRINK ENERGY T24
Z Z •� Certified copy iz fled with fie city inspection division. MISC.- REFER TO ORD.
0 Apbfcam Y ❑ N❑ Y ❑ N❑
Cr Ln CERTIFICATE 01'EXENIN[ON FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOOZONE A.L.U.O.
LU > COMPENSATION INSURANCE: PLG.CONTE. LIC.NO. PLG.
CL 0 OIRS section need not be completed if fisc permit is for one TOTAL Y❑ N❑ Y [:] N❑
hundred dollars(81001 or less.) - ,
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I sball not employ any person in any manner so as to
O w become suhjca 16 the Warkcd Compensation Laws of California.
BUILDING rN
a Dam Applicant ALTER OR ADD TO MECH. / 4.00 ( —
} 0 NOTICE '10 AI'I'LICAN'f: If,after making this Certificate of L. -
F ? empties",you should bucone sobjca to file Worker,'Compensation APPLIANCE a 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 10000C.F.M) 3.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 5.00 SEISMIC FEE 8- 1/4
1 hereby affirm that there is a construction lending agency lot EXHAUST HOOD(WITH DUCT) 2.00
file performance of file work for which this permit is issued(Sec. MICROFILM •0.
3097,Civ C.). HEATING UNIT ITO 100,000 B.T.U.) 4.00
LCDdR,Name !9 A- HEATING UNIT 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 380
information is correct. 1 agree to comply with all city and county PLUMBING
aNinances.and state laws relating to building construction, and BOILER-COIYIP(3H.P.or1O0,000B.T.U.) 4.00
hereby authorizn...ogrescnlalivcs of this city In curer upon the BOILER-COMP IOver 100,1300 BTUI SEE FEE SCH. MECHANICAL
above-mentioned properly file inspection purposes.
(We) agree to ave, Inde unify and keep Ilmmlese the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way acerae against said City in C.e.quenc.of the PERMIT ISSUANCE 3.00
grantm of th ' mil. MECH.CONT. LIC.NO. MECH.
bpi �*"n Z-�,��T TOTAL TOTAL 37, 7
Signature of Applicant/Contractor Date
'INSPECTOR COPY