C7133 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
BU LDI NG PROJECT 1 DENTI FICATI ON PERMIT NUMBER
�( BWLDING
APPLICATION & PERMIT
ADDRESS BUILDING-ELECTRICAL-PLUMBING-ME
-MECHANICAL
p /G
7133
7 PLAN CHECK VALIDATION
NAME 7��/�S°ZsJ OTV. ELECTRIC PERMIT FEE �.5z`
• FACTORS vHONE
n
AREOUTLETSUTLETS-SWITCHES-RECEP 5.00/1.00 7d 2d UC.NO. LIGHTING FIXTURES 5.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00 "
ADDRESS
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHEC7 P.C.NO,
OR
ENGINEER ,1 LIC No. SIGNS TRANS. 3.00
ADOREss eruct SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
APPLICANT
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
woo LICENSED CONTRACTORS DECLARATION
¢ u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
Z i fcommencing wrath Section 7000)of Division 3 of the Baines and BLDG. ELECT. PLG. MECH.
F y i Pneess,%i CodcLn I my keens"is N full force an eHc/ yly J ❑ ❑ ❑
D o m - License Class /I__,.. _-_-Lia NumM1er O d
0 m t Date_1..1 � Y Cmltnclur
BUILDING PERMIT
¢ ¢ ¢ OWNI R-BUILDF-R DECI-ARATION
o.a ° MISC.- REFER TO ORD INFORMATION
w 3`u_ I hereby affirm that I am exempt from the Contractor's License vgLUATION $/FT.
u_ O a Law for the following reason.(Sec.703 t.5,Business and Professions PERMIT ISSUANCE 6.00
� - Codc Any city or county which requires a permit construct,alter, w- l/ n Alis
¢ ¢ ¢ p improve,demolish,or repai any structure,prior to its issuance also ELEC.CONTR. LIG.NO. ELEC.
a w m u requiies the applicant for such permit to file a signed statement that ^-�Y, TOTAL PERMIT TO ••:T,
he is licensed pursuant to the provisions of the Contractor's License
F z a
Law(Chapter 9(commencing with Section 7000)of Division 3 oftlne
4 o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
at H $ oto basis for the alleged exemption.Any violation of Section 7031.5 1STORIES TYPE CONSTR.
n3by any applicant for a permit subjects the applicant o a civil penalty gLTER-DRAIN -WATER (EA.) 4.00
- of not more ran five hundred dollars(5500).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2,00 OCC:GROUP RES.UNITS
their Cole 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
Cade:"file 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 re through his own employees,provided that such improve-
ments are through des or employee sale.provided
that s the building GAS-EA.SYSTEM-1 1NC.4 OUTLETS 4-00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 (EA) 1.00 BUILDING USE
builder will have tile - . - ,
e burden of proving that he did not build or im- RES IND N vB ^Onber
prove for i purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property,on exclusively contracting with 1:1 El
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSO SPARCEL NO.
and Professions Code:"Pile Contractor's License Law does not apply -
to an owner of property who builds or improves theraon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a comractons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.2001t/8.00 TRACT NO. PARCEL NO.
❑ l am exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT' 4.00
reason
Owne Cate - WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
wORKI;Rs'Co MP174SA'1'ION I)I:CLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that Phase a certificme of consent to sell-insure,
or a certificate of Workers'Compensation Insurance,or a certified 1 'ZONING ENG?SITE N0,
copy thereof(Sec.3800.Lab C.).
Policy No. Company
O ❑ Cunilied Copy is hereby furnished. RE SPRINK ENERGYT2A
z Z' ❑ Certified copy is filed with the city inspection division.
O Applicant MISC.- - REFER TO ORD. Y[J N❑ Y ❑ NF]
~ tiPERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.G.
Lu
CER"I'114CAT1i OF EXEMPTION FROM WORKERS' t/
W > Cl1Ml'IiNSAI'ION INSURANCE �` PLG.CONTR. LIC.NO. PLG. Y❑ N❑ Y❑, NF]d O IThis section need not be completed if the permit is for one TOTAL
D Z hundred dollars IS 100)or less I
U O 1 certify,that in the performance of the work for which this per- OTY. MECHANICAL PERMIT, FEE FEE SUMMARY
LL F mit is issued,1 shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California. /� Qb
O 0. Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING ](U Q'
} W NO"TICI!TO APPLICANT: It.alter making this Certificate of Ex-
Z caption,you slmuld 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.NL) 3.00
CONSTRUCTION LENDINC AGENCY AIR HANDLING UNIT(OVER 10ACC.F.M.) 5.00 SEISMIC FEE
1 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(See. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name H EATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 3.00
information is Correct.1 agree to comply with all city and COunty PLUMBING
tieordinances and state laws relating to building construction,and BOILER-CONP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorim representatives of this city to enter upon the BOILER-COMP(Ovmr 100,000 BT6)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
may in any way accrue against said City in Consequence of the PERMIT ISSUANCE 3.00
/ granting of this permit MECH.CONT. LIC.NO. MECH.
J alum 0 c o l er e I
TOTAL TOTAL has ser
'. INSPECTOR COPY .