C7205 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 1 �o�
AooREss 0. ,' ,^
IA Y1 BUILDING-ELECTRICAL-PLUMBING-MECHANICAL `
WNER'5 VVV���AAAJJJ PLAN CHECK VALIDATION
NAME r' QTY- ELECTRICPERMIT ' FEE
UNE
CONTRACTORS
NAMt Ate( TLETS-SWITCHES-RECEP 5.00/1.00
^j,y
JG. 6 LS L.C.LIC.NO. 30KI� LIGHTING FIXTURES 5.00/1.00
ADDRESyyS,�TORS -h 'I
-APPLIANCES-RESIDENTIAL 4.00
R7I�THONE(C11S (fj' PANELS 5.00 DATE OF APPLICATION
ARCHITECTSIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
SS
ZIP EMP.METER OR POLE INS. 15.00 `
APPLICANTS MOTORS SEE FEE SCH. S
ADDRESS9
SERVICE CHANGE 10.00 .Y/,/�Si
wo o LICENSED CONTRACTORS DECLARATION
G U U I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
N G w (commencing with Section 7000)of Division 3 of the Business and BJ I ELECT. I PLG. MECH.
0. Professions Code,and my license is in full force andef ect.
z r0 m License Lic.Number Sd5 Q
om w Date Y 27 hS Cnrnmctor t"
x a 4 OWNER-BUILDFR DECLARATION I BUILDING TION .1.
0 INFORMATION
o A. LI MISC.- REFER TO ORD
3 a- r I hareby Alirm that I am exempt from the Contraelor's Liccnxe VALUATION $/FT.
FLLOA Law for the following reason,(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00
Code:Any city or county which reqm in a permit const rucl,alter.
rt oa Q Q improve,demolish,or repair any structure.prior to its issuance.also ELEC.CONTE. LIC.NO. ELEC. D(/l/7/z
- DLL requires the applicant for such permit to file a signed statement that TOTAL P MIT TO
A w $ he is licensed pursuant to the provisions of the Contractor's License
F z i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
r o the basis for the alleged exemption.Any violation of Section 7031.5
STORIES TYPE CONS fl.
by any applicant for a permit subjects the applicant to a Civil penally ALTER-DRAIN -WATER (EA.) 4.00
of not mom than five hundred dollars($500).):
❑ 1,as owner of the property,or my employees with wages as BACK F LOW PROTECT.DEVICE 2.00 Oce.GROUP REB.uNlis
(heir sole compensation,will do the work,and the Structure is but
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 thereon,and who does such work FIXTURES-PER TRAP - 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees.provided that such improve-
memsare not intended oroffered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner. GAS-EASYSTEM-OVER 4(EA.) 100 BUILDING USE
builder will have the burden of proving that he did not build or im- . . .
RES IND O PB Omer
prove for purpose of sale.l. INDUSTRIAL WASTE INTER. 20.00 RE IN
❑ 1,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: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
contracts for such projects with a contractods)licensed pursuant to
the Contractor's Llcensc Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I om except under Scc. ,BAP C.fir This WATER HEATER W/VENT 4.00
l'a)on
Owner Date WATER SYSTEM 4.00 ACC.DATE ACG FILE NO.
WORK ERS'COMPFNSATION DECLARATION WATER TREATING EQUIP. 4.00
' ^ 1 hereby affirm that I have a certificate of consent to self-insu m,
or a certificate of Workers'Compensation Resonance,or a certifi'd ZONING ENG.SITE NO.
copy thereof(Sec 3800,Lab.C.L ,I p
Policy No.-I9�L�CompunY r- •
0 ❑ Certified ropy he fumishc FIRE SPRINK ENERGY T-24
z Z ❑ Certifned,Apl>�II� iL' rillitY inspection division.
0 Applicant �s Q �A- MISC.- REFER TO ORD. YE] NEJ
CC W CENT IF'ICATI?OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE
W > COMPENSWION INSURANCE PLG.CONTE. LIC.NO. PLG. V� NE] Y � N�
EL,C) This section need not be completed if the Permit is for one TOTAL
:xZ hundred dollars(SIDG)or less.)
U O 1 certify that in the performance of the work for which this per. OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,1 shall not empluy any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
UJ
Dam Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} u! NOTICE"TO APPLICANT: IL after making this Certificate of Ex-
Z emption,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)0000F.M.) 3.00
CONST RUCI'ION LF?NDING AGENCYAIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I herehy 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,Cie.C.). HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Name-
Lender's Address HEATI NG UN IT(OV ER 100,000 B.T.U.)7.50 ELECTRIC
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
ordinances and state laws relating to building construction, and BOILER-COMP(3H.P.or100,000B.T.U.1 4.00
hereby authorize representatives of this city w enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
mayin en ay accrue again said City In consequence of the PERMIT ISSUANCE 3.00
grant f spanil. �$ MECH.CONT. LIC.NO. MECH. r
� Z' $ TOTAL TOTAL
Signature of Applicant/Contractor Date
INSPECTOR COPY