7151 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDING PROJECT I DENTI FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT 7151
pOORESs.,
59 G� A BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S , PLAN CHECK VALIDATION
•
" PHONE AMCAME QTY. ELECTRIC PERMIT FEE
1 I
CDNrnacrDR's UTLETS-SWITCHES-RECEP 5.00/1.00
NAME
LIC.No. Q LIGHTING FIXTURES 5.00/1.00
CONTRACTORS [APPLIANCES-RESIDENTIAL 4.00
ADDRESS
/7�Q VHONE ' 1� PANELS 5.00 DATE OF APPLICATION
ARCHITECTSIGNS 6,00 PLAN CHECK FEE P.C.NO.
OR
)., ENGINEER -
uc.No. SIGNS TRANS. 3.00
ADDRESS SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
1 ZIP TEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH. _J
. .� AODness 17
KI SERVICE CHANGE 10.00 p
.\w o O LICENSED CON TRACTORS DECLARATION ��I/S/
Qt v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
m G m (conlomncing with Section 7000)of Uivisian 3 of the Business and BLDG. ELECT. PLG. MECH,
,m z Professions Code,and my license is in full force and effect. ❑ ❑ ❑ ❑
z O'rn- License Class Lic.Number
O m - D Dale Conlraclor
¢ xf " BUILDING PERMIT
¢ ¢ w a OWNER-BUILDER DECLARATION
A o a p MISC.- REFER TO ORO INFORMATION
w 3 u w 1 hereby affirm that I am exempt from the Contractor's License VALUATION E/FT.
F u O J Law for the following reason.(Sec 7031.5,Business and Professions PERMIT ISSUANCE 6.00
FywCode:Any city or county which requires a hermit to construct,alter, ELEC.CONTE. LIC.NO.
¢ a O improve,demolish,or repair any structure,prior to its issuance,also EL C.
IE O¢ requires the applicant for such permit to file a.igned statement that TOTAL PERMIT TO
d w m�` Ise is licensed pursuant to the provisions of the Contractor's License
F z Law(Chapter 9(commencingwith Section 7000)of Division 3 of(he
a PLB lT"
4 O Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
LE the basis for the alleged exemption.Any violation of Section 703 L$ STORIES TYPE CONSTR.
by any applicant lot a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not Gore than five hundred dollar,($500).j:
t Cl I,as owner of Ore property,nr my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sale 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:'fire Contractor's License Law does not apply to an owner of
s, property who builds or improves thereon,and who does such work 4f FIXTURES-PER TRAP 4.00 SQ FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
then,are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.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-
'L prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 20.00 RES Irv. PB Omer
❑ I,as owner of the property,am exclusively contracting with E:] E] 0 E] E]
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The 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
for x such projects with a colicensedo0 sl licensed pursuant t
the CO is for s i h pros Law. o SEWER-SANfTARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
'
❑ IansexlQ,Runder Sec. ,It.&P.C.for this WATER HEATER W/VENT 4.00
reason
Owoer Dare WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSA NON ULCLARATION WATER TREATING EQUIP. 4.00
I lwrcby affirm that 1 have a certificate al'con,cut to'el Flnsure' ZONING ENG.SITE NO.
ertificate of Worked Co To......non Insurance,ar a Ler(fflcd _
copythereofl Sce.3800,L.b.CJ.
Policy No, Company
0 ❑ Certified copy is hereby furnished. •q FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is filed with the city inspection division.
REFER TO ORD
MISC. R '
U Applicant - V ❑ rv❑ Y ❑ N❑
W CERTIFICATE OF EXENIPTION FRONT WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU7 CO.,IPENSATION INSURANCE PLG,CONTE. LIC.NO. PLO. L `X_-y LR/oZ Y❑ N❑ Y❑ N❑
fL Z -(Tliis section need not be completed if (he permit is for one TOTA
hundred dollars IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
L1_ P: Inir is issued,I shall not employ any person in any manner so as to
U become subject to the Werkers'Compensalion Laws of California.
a Dan' Applicant ALTER OR A
>_ to TO MECH. 4,00 BUILDING
to NONCE '10 APPLICANT: If,alter nmking this Ce,Lffc.te of Ex-
F Z mnptiuo,yro should become subject to tint 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 10,000GF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10A00C.F.M.) 5.00 SEISMIC FEE
I hereby affirm Thar 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.L HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lenders Name - HEATI NG UN IT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
• information is correct, I agree to comply with all city and county PLUMBING 0�02_W
ordinances and state laws relating to building construction, and BOILER-OOIVP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authoroc representatives of this city to enter upon the BOILER-COMP (Over 100.000 BTU)SEE FEE SCH. I MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep Imnmless the 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 consequen of they
grant) It �.E MECH.CONT. LIC.NO. MECH.
per w �j f, 6- MECH.
TOTAL ow TOTAL
Sig azure of A pplicant/Cdnlractor Date
INSPECTOR COPY