C 7177 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALLPOINT PEN ONLY
- •BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
8 ,NG APPLICATION & PERMIT
-T OOR SS7177
nn -BUILDING -ELECTRICAL-PLUMBIyN{G-MEpCHANICAL
NNMERa - VALIDATION
x� /2J Q '�If OYy,.,FK'
`I 1' - Y ELECTRIC PERMIT " 9r' T F,�EE .
CONTRACTORS UTLETS-SWITCHES-RECEP 5.00/1.00
ft11111A .No's"L/580 LIGHTING FIXTURES 5.00/1.00
CONTRACTORS APPLIANCES,RESIDENTIAL 4.00
b//�1 P11O1NE2 PANELS 5.00 DATE OF APPLICATION
OR
ARCHITECTSIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEERur
c.•No. -. SIGNS TRANS. - ` 3.00
ARC" OR ENO, SPECIAL CIFICUIT 5.00 PERMIT VALIDATION
ZIP frEMP.METER OR POLE INS. 15.00
aPPuc ISE
POREAN
S$ MOTORS SEE FEE'SCH.
•
SERVICE CHANGE 10.00
w o o LICENSED CONTRACTORS DECLARATION
a u 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
m G w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H n z Prolessinns C ,;IR iM�(license is in full m s d T - ❑ ❑ ❑
,I o m Licensyf-lass 1 I`Lie,
Numbe V -
o N F w pale Contractor , -
S, s BUILDING PERMIT
re" w ¢ OWNER-BUILDER DECLARATION �-
A o A " MISE.- REFER TO ORD e�- IN,ORMAT 0
X ;U.. h I hereby affirm that I am exempt from the Contractor's License
r LL U.a, law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00
VALUATION SIFT.
Code:.Any city or county which requires a permit to construct,alter,
a�" improve,demolish,or repair any structure,prior 10 its issuance,also ELEC.CONTR. LIC:NO. ELEC.
o w requires the applicant for such permit to file a signed statement that TOTAL
w hPERMIT TO
e Is licensed pursuant to the provisions of the Contractor's License - '
i law(Chapter 9(commencing with Section 7000)o'Dlvision 3 of(Ito a ' Sa' x. 1 t +7 i•, - I;�,
i ¢o Busmessand Professions Code)or that hMB
e Isexempt therefrom anti j • PLUING PERMIT s 1.''S F,EE
¢ I- the basis for the alleged exemption.Any violation of Section 7031.5
1 4 STORIES TYPE CONSTR.
c;_ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of Rot more than five hundred dollars($500).):
❑ 1,as owner of the property,or my employees with wagesas BACK FLOW PROT T.DEV IC 2:00 OCC.GROUP RES.UNITS
their E)le conlpema(ion,will do the work;and the structure is not -
intended or offered for sale(Sec. 7044, Business and Professions / DRAINS-FLOOR OOF AREA,C ND. 4.00
Code:The Cmau cmr's License Law does not apply to an owner of ,
property who builds or improves themon,and who does such work FIXTURES,-'PER TRAP 1 4. 50.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
r meets are not intended or offered for sale.If,however,the building GAS-EA.SSTEM-11NC.4 E S 4.00
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OV ER 4( As) 1100'tlnu
builder will have the burden of proving that he did not build or int. _ BUILDING ON USE
prove fill purpose nfvleJ. INDUSTRIAL WASTE NTE ' 20.00 RES IND CON pe Omar
❑ I,as owner of the properly,am exclusively contracting with 0 0 0 0 ❑
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
....tracts for such projects with a contme(o-S)licensed pursuant toe-
the
oSEWER-SANITAR V-STORM EA.'200ft/8.00 r
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ Iam'cxcmpt..ndcr Sec. - ,B.&P.C.for this
reason WATER HEATER W/VENT 4.00
Owner DateWATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00 ,
I hereby affirm that I have a certificate of consent m self-insure,
or a certificate of Workers'COMP nsali n Insure or certified ZONING ENG.SITE NO.
it
copy it, pf alit-)
Policy fJf(L1L'!."1[ panY
O Certified copy is her by furnished.
Z 2 Ce r ifi• 'opy isf_le� �r(f� city inspection division. FIRE SPRINK ENERGY T-24
O_ Pplicant f�d.df IMISC.- REFER TO ORD. YE] N❑ YF] N�
W Cl-RT I FI CAIIi O F eX1:M PI ION PROM WO R K Ii RS' PERMIT ISSUANCE 6.00 -- FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCEP C{yIT PLG. �y
0- Z This section need not.be completed if the permit is for one Y M TOTAL •J p 0 Y❑ N Y NE]
hundred doll...1$100)or less.)
U O ' I certify that in the performance of the work for which this Per. (]TY" " -MECHANICAL PERMITi,• FEE" ''FEEsySUMMAMRJY
LL F- mitis issued, I shall not employ any person in any manner so as to
O W become subject to the Workers Compensation Laws of California.
a Date Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} rn NOTICE TO APPLICANT: If,after making(his Certificalc of Ex-
H ? emotion,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 pemtit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.NL) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.EM.) 5.00 SEISMIC FEE
Thereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
Ore performance of the work lot which(his permit is issued(Sec. MICROFILM
3097,CmC.L HEATING UNIT(TO 100,000 B.T.U.) 4.00 '
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information n correct. I agree to comply with all city and county. PLUMBING
ordinances ormatio and state laws relating to building construction, and BOILER-COMP(3 H.P.or.100,0006.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP 10.,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
oniay any way accrue a Inst said City in consequence of the -PERMIT ISSUANCE 3.00 tt npernmL /7 / / MECH.CONT. LIC.NO. MECHGJJ1 rJ� TOTAL TOTAL'
r of Applicant/Con moor ' Ume
OFFICE COPY