7115 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING / ,r C APPLICATION & PERMIT 7115
aDORe55
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OwNEH'S �� ]��_��� �/� PLAN CHECK VALIDATION
. NAME V' � QTY. ELECTRIC PERMIT FEE PLAN
ONF ��//r
7CONTRACTORs OUTLETS-SWITCHES-RECEP 5.00/1.00 '^�1
rvA E (jja
UC,.O. /f6 LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S APPLIANCES-RESIDENTIAL 4.00hJ
'
4DD ESS
3 PHONE ya7- PANELS 5.00 DATE OF APPLICATION
ARCHITECTSIGNS 6.00
PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LTC.No. SIGNS TRANS. 3.00
AARCH.OR DDRESS ENG. SPECIAL CIRCUIT 5.0Q PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
APPLI MOTORS SEE FEE SCH.
ss
ADDRDDR ESS
SERVICE CHANGE 10.00
0 SC o O LICENSED("ON']RACTORS DECLARATION
¢U v I hereby'Minn that 1 am licensed under provisions of Chapter Y ISSUANCE DATE
m rt H (commencing with Section 7000)a1 Division 3 of the Business and eLDG. ELECT. PLG. MECH.
F. m z Professions Codc,and nsy license is in full fore and effect. ❑ ❑ ❑
2 o vs Leena Glass Lie Number Y4 /O -
o Date Contractor
a m s BUILDING PERMIT
¢ a, w a OWNER-BUILDER DECLARATION INFORMATION
waA " MISC.- REFER TO ORD
g; y 1 hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
F l� oa Law turthe following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00
Code:Any city or county which reyuires a permit to construct,alter,
¢ ¢G 0 imp rave,demolish,ar Repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
0 a, requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
a w m he is licenced pursuant to the provisions of the Contractor's License
r z i
Law(Chapter 9(commencingwith Suction 7000)of Division 3 offle A
a Business and Professions Code)or that he isexempt therefrom and OTY. PLUMBING PERMIT FEE /l
Q o the basis for the alleged exwnption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
dam _ by any applicant for.permit subjects the applicanuoadvilpcnally ALTER-DRAIN&VENT-WATER (EA.) 4.00
01 not more than five hundred dollars($500).):
❑ I,as owner of the property.or 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,AR EA,COND. 4.00
Code:The Contractor's License Law docs 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 ill
himselfor through his own employees,provided that such improve-
mentsareno(intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improvement is sold within one year of connpletion,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 on-
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 200p .Es IND ' C PB Omer
LII,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 ASSES50 5 .CEPILL
O.
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 lin such projects with a conlractous)licensed pursuant to
the Ccmractur's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ 1 con exenmt un der Sec. ,B.&PC.far His WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORT:F RYCOMPENSATIT ON DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that 1 have acertificate ofconsenlloself-insure.
ca
or a aerlilite of Workers'Compensation Insurance,oo a ceRified ZONING ENG,SITE NO.
copy thereof(Sec.3800.LBb.C.),
rat b. Company
O CeRitied copy a hereby furnished. FIRE SPRINK ENERGYTZ4
�L-l-Gec ifi• Cod
IkQ with it inspection division. MISC.- REFER TO ORD.
� O Applicant L Y ❑ NO
Y ❑ N❑
2rn 'I'IFICA'1'E OF EXEMPTION FROM WORKERS'- PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
Z (' Phis section need not be completed'if,the permit is for one TOTAL Y❑ N❑ y F] N❑
hundred d.11...($100)or less
U O 1 certify that in the performance of the work for which this per QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H nut is issued,I shall not enOmloy any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
O ED Date Applicant ALTER OR ADD TO MECH. q,pp BUILDING
} W NOTICE '1O APPLICAN"I': IL after making this Certificate of Ex-
F ? eruption,you should become subject to the Worker,'Compensation APPLIANCE 4.00 PLAN CHECK
provision 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.M.) 3.00
1 AIRHANDLING UNIT(OVER IO,000C.F.M.15.00 SEISMIC FEE
CONST'RUCI'ION L17NDING AGENCY_ e
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(Sec. •MICROFILM
3097.Cre.C.), HEATING UNIT(TO 100,000'B.T.U.) 4.00
Lender's Name HEATING UNIT(O VER 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 withall city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COW(3 H.P.or 100,000 B.T.U.) 4.00
hereby emlmr,,, representatives of this city to 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 o1 MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which - CONST.TAX
may in any way t cnat,against mid City in consequence of the PERMIT ISSUANCE 3.00
grantin of this permit. MECH.CONT. LIC.NO. MECH.
Gl �i7LLuv TOTAL TOTAL 1 aJ
Signature of Applicants t/Contractor Dale ro,�
INSPECTOR COPY �
�t