7080 APPLICANT TO FILL IN INFORMATION WITHIN RED-LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS /9g/ 7"„/itiGNr Cr. 7080
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'5 PLAN CHECK VALIDATION
"AME TY. ELECTRIC PERMIT FEE
PHONE 2q,
CONTRACTORS UTLETS-SWITCHES-RECEP 5.00/1.00
NAME {� I' //��
^t)9ri/UC Lr.,sG 4/y/� LIGHTING FIXTU RES 5.00/1.00
ADNTRAcroR's / �Q 0E37-1-)07-,577 PPLIANCES-RESIDENTIAL 4.00
CONTRACTORS
PRONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER LIC,NO. SIGNS TRANS. 1. X3.00 1 (
AARCHOR DDRESS ENG. SPECIAL CIRCUIT 5.00 / PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS. 15.00
APPLICANT rv $ MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00 ,f/l
0 o O LICENSED CONTRACTORS DECLARATION
a u I hereby affirm that I um licensed under provisions 111 Chapter 9 ISSUANCE DATE
v, G w tttunmcncing wi111 Section 7000)of 1livision 3 Of The Business mW BLDG. ELECT. PLG. I MECH.
H z z Professions Codc, d/1 y iecree is in full furcejuld • ec. ❑ ❑ ❑
z O - License Chasg_ Lic.Number
p Z - p
Uatc_L� Contractor +N µr+'
y BUILDING PERMIT
¢ Ix CE w u OWNER-BDILDER DECLARA'I']ON INFORMATION
AOA MISC.- REFER TO ORD
w S LL r I hereby affirm that 1 am exempt from the Contractor's License VALUATION $/FT.
H u tL a Law for the following mason.(See.7031.5,Businessand Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to construct,utter,
pimprove,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
u w m LL requires theapplieant for such permit to Gl...igned statement that - TOTAL PERMIT TO /
he is licensed pursuant To the provisions of the Contractor's I.iLYnu C�_r�'/r-
F z <
Law(Chapter 9fcommencing with Section 70001 of Division3of the
If usmess and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
I C, the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a � by any applicant for a Pc norm subjects fhc applicant to a civil pnwlly ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollar,(S500L).
❑ 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 tie work,and the structure is not
intended or offered for sale (See 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Colic:The Contractors 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-
' merits are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improvement is uMd 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 ince RES IND CON PB Omer
prove for purpose of role.). INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑ ❑
❑ d as owner of the construct
am exclusively contracting with
licensed contractorsCod to construct the price.(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions property Con truemr's License Law docs not apply
to nn owner of property who builds or improves Thereon.,and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00
contracts for Buell projects with a contractor(s)licensed pursuant to
1 the Contractor's License Law. SEWER-SANITARY-STORM EA.2001t/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,BAP.C.for this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACG FILE NO.
WORKERS'COMPF-NSAIION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent to snit-insure, ZONING
or a certificate of Worker,'Compensation Insurance,Ur a certified ENG.SITE NO.
copy thercol(Sec 3900Lab,CJ) ^s
Policy No.Z /� //rA Co;lnpapY �&IZ
0 ❑ etlifie op5is hereby rushed FIRE SPR INK ENERGY T-24
Z 2 Iertil is p s fie 'ith I• city inspection division. MISC.- REFER TO OR
p Applicant- I V❑ N❑ V ❑ N❑
c w CH RTI EICATE OI'I;X ISM P I IOA FROM WO R K Ii RS' PERMIT ISSUANCE 6.00 FLOODZONE A.L.U.C.
LU COA11'IiNSATION INSURANCE PLO.CONTE. LIC.NO, PLG.
L ❑ ffhis semilin need not be completed if tet permit is For one TOTAL Y❑ N❑ Y ❑ N❑
Z hundred dollarsl51000of less.)
U O 1 ceHR, that in the performance of the work lin which this fier- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mil is issued,I shall not employ any person in any manner so as to
U become subject Io the Wmkcrs Compensation Laws of California.
d Dale Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} w NOl IC17 TO APPLICANT: IL after making this Certificate of Lx-
r Z_ C,n,tion,you should becunesubjecl to the Workers'Compema6on 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.M.) 3.00
o,
CONS'TRUCI'ION LENDING AGENCY AIR HANDLING UNIT(OVER 10SWC.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction Ialding agency for EXHAUST HOOD(WITH DUCT) 2.00
tire 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 HEATING UNIT(OVER 100,000 B.T.U.P.50
Larder's Add«ss ELECTRIC
certify that I have read this application and state that Oce above VENTILATION FAN (SINGLE) 3.00
information is .reed. I agree to comply with all city anJ county BOILER-COMPI3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and slate laws relating to building construclion, and
Hear
authorise representatives of this city b corer upon the g01 LER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mens Tuned property for inspection purposes.
(WC) agree to save, indemnify and keep Imrmless the City of MISC.- - REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
ria any way accrue against said City in Consequence of the PERMIT ISSUANCE 3.00
gra hng it's perm k MECH.CONT. LIC.NO. MECH.
(L--�'.1//1,��[[11 / }I/I /• �f TOTAL
Igna oAppeant/'ont7ad�� rLate� ��� '/�T/'tib "~7t/ 7. 00
TOTAL
INSPECTOR COPY