7034 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
22 / O yrlt= BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 7034
NAMURAINILH
S. O� O1•✓�e S �SSO PLAN CHECK VALIDATION
MC�IM1 Jr- HONE QTY. ELECTRIC PERMIT FEE
O
CONTRACTOHs UTLETS-SWITCHES-RECEP 5.00/1.00
NAME
Q LIC.NQ3 Z V 1, LIGHTING FIXTURES 5.00/1.00
CONTRACTORS Rd Sff. PPLIANCES-RESIDENTIAL 4.00
AOOREss Il
Z nrvE2J 7 q PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.DD PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIc.NO, SIGNS TRANS. 3.00
ADDRESS LNG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 5.00
Av
ADDRESS vuCANTS MOTORS SEE FEESCH.
SERVICE CHANGE 10.00 i/�
uoFs o o LICENSIi1)CON'T'RACTORS DECLARATION 'T
a m I hereby affirm That I in licensed under provisions of Chapter 9 ISSUANCE DATE
m <w (commencing with Section 7000)of Divinols3 of the Business and IROD ELECT. PLG. MECH.
h z I'rofesslom Co and y license is in full Cry got }J�^ / ❑ ❑
i o m - Licenu Class-�1prl Lic.Number
.l if b I ❑
0 v, -D I Dale Contractor
y s ' BUILDING PERMIT
Or R w < - OWNER-BUILDER DECLARATION
MISC.- REFER TO ORD INFORMATION
w 3 u I hmeby allinn that I am exempt Innn the Contmetor's Liccnse VALUATION $/FT.
Fuoa Law lin the following reason.(Sec.7031.5,Businessand l'nslessions PERMIT ISSUANCE 6.00
Code:Any city Or county which requires a permit to construct,alteq
2¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. - ELEC.
ou
-0 2 requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
K
m m he is licensed pursuant to the provisions Of the Contractors License
HZo- Law(Chapter 9(commmocingwith Section 7000)of Division 3 ofthe
a Business and Pocksuile,Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
X = $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
uR by any applicant for a permit subjects the applicant to a civil 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 sole compensation,will do the work,and the sl ructure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Cndei The Contractor's License Law docs nett apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SQ FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such Improve-
mems are not intended or offered for Colo.IL howeveq the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM.OVER 4 IEA.) 1.00 BUILDING USE
prove for purpose of sale). INDUSTRIAL WASTE INTER. 20.00 E IND CON vR Omer
131,as owner of the property,am exclusively ntracting sively cowith ❑ ❑ ❑ ❑
licensed contractors to amstmct the project(Sec-7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 1 ASSE55ORSPARCEL NO.
and Professions Code:The Contractors License Law Jots not apply
to an owner of property who builds or improves[hereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts fur such projects with a contractons)licensed pursuant to
Bre CO tractor's License law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ Tum exempt under Sea ,B.&I'.C.Ii)r this WATER HEATER W/VENT 4.00
sol
Owner Dale WA R SYSTEM 4.00 ACC.DATE ACC.FILE NET
WORT:ERS'COJM PENSAT1ON,DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate ofconsent to sel Ginnue' ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
cop,t hereof ISee.3800,1ah.0 I
policy No. COlnpw,y 1I �(f-S
❑ Cenllfled copy s hereby furnished. (r� FIRE SPRINK ENERGY T-24
Z ❑ C'ertified opy is 11e 'h the city in"t, lion division MISC.- REFER TO ORD.
O APPlicant - Y❑ NE) Y ❑o NEI
Cy CIiR'1�I'1PIC`ATIi OVVPIixISA7 PTION PROM WORKIiRS' PERMIT ISSUANCE 6.00 FLOOD ZONE A,LU.C.
LOU 1 CObIPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG,
CL 0( '1hi,s section need not he completed if the permit is for one TOTAL Y❑ N❑ F]Y N❑
hundred dollars IS 100)or less.
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers Compensation Laws of California.
W Dmc Applicant ALTER OR ADD TO MECH. 4.00 BUILDING 5
} to NOTICE 'f0 APPLICANT': IL after making this Certificate of Ex- '
Z caption,you should become subject to the Worked'Cmnpcnsatiod APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you most forthwith Comply with - FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTROCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE S�
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C., HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Name HEATI NG UNIT(OVER 100,000 B.T.U.)7.50
lender's Address ELECTRIC
Icertily that lhave read this application and some l hat OCabOv0 VENTILATION FAN (SINGLE) 3.00 \
information is correct. I agree to comply with all city and Loamy PLUMBING
ordinances and state laws relating n) building cunMEtation, an
BOILER-COMPI3 H.P.Or 100,0006.T.U.) 4.00
hvohy melons, ep,esentativu, of this city to enter upon the BOILER-COMP love,100,000 BTU)SEE FEE SCH. MECHANICAL \
above-mentioned property for inspection purposes-
(We) agrcc to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino .,most Ila blit 135,)udgmm costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against W C ty in consequence of the
gra Fthis,pe L e MECH.CONT. LIQ NO. MECH.
2-2�- DT"` TOTAL 33 u
Signature of Applicant/C'ommdor Dale
INSPECTOR COPY -