7235 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
- BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 7235
ADDRE ` n/�
/ I � 111J! BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
� 1 � K /
OWNER'S - /1 PLAN CHECK VALIDATION
NAME \ ���({ �JSIGNS
ELECTRIC PERMIT FEE
• PHONE
coNTRAcrons UTLETS-SWITCHES-RECEP 5.00/1.00
Ti ,�j Lt•
i LIC.No./(� 'yIGHTING FIXTURES 5.00/1.00 '
r-ONTRACTOH'S PPLIANCES-RESIDENTIAL 4.00
,�/�0 PHONEr 'Jr7-7/fANELS 5.00 DATE OF APPLICATION
ARCHITECT r- IGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEERuc.No. TRANS. 3.00
ADDRESS ENC' SPECIAL CIRCUIT 5.00 PERMIT
'VALIDATION
��
ZIP TEMP.METER OR POLE INS. 15.00
Arvrs MOTORS SEE FEE SCH.
ADDRESS Ess
SERVICE CHANGE 10.00
oo LIC17NSIi U CON'1'kACI ORS DECLARATIONc u u I hereby affirm Ilett I am licensed under provisions ol'Clapter 9 - ISSUANCE DATE
m Q w (conutu•nciug with Section 7000)of Uivisimt 3 of the Business and BLDG. ELECT, PLG. MECH.
F w z Proncssions CodOpti1ty kcnsc is in full) rJx4ln yffeC,p� ❑ ❑ ❑
z i m D License Clan Lie Numhe
9 r Dule '�- _ Contractor
a r BUILDING PERMIT
Ie re a OWNI:R-Iil1ILU1!R UBC[.AkA'I'ION INFORMATION
r MISC.- REFER TO ORD
u 1 hereby affirm that I um exenlpl fnnn the Cnnlraulars License
LL o¢ PERMIT ISSUANCE 6.00 Lnw for Ihu following reason.ISec.7031.5,Ine,inessand V,or"xioos VALUATION $/FT.
-' Codc:Any city or county which requiresa permit mcon'UncLahcq
SE ¢ a a improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC. (/
o LL requires the Tpplicunt for such permit to file u signed statement that TOTAL 5Rrvt1
A uI i w he is licensed pursuant to the provisions of the Contractor's License T TO
nse //J_)
FiLaw(Chapter 9(commencing with Section 7000)of Division 3 of l he
- a Business and Professions Cade)or Olin he is exemptrom;therefid QTY. PLUMBING PERMIT FEE '
Se rDo the basis tier the alleged exemption.Any violation of Section 7031.5 TORIES T PE CONSTR.
L. by any applicant for a permit subjects the applicant lea civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of out more than five hundred dollars 05000.):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 DCC.CROUP RES.UNITS
their sole compensation,will do the work,and the structure is Te
intended or offered for sal,(Sce. 7044, Business and Professions - DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractors License Law does not apply to an owncrof,
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 4.00 SD.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees.provided that such improve-
cnts are not intended(it offered for sale.If,however,the building GAS-EA.SYSTEM-l1NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS yEA.SYSTEM-OVER 4(EA.) 1.00 eulLDlrvG USE
builder will have the burden of proving that he did not build or im- E IND CON PB Omer
prove for 1.as purpose of the
INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑
❑ L as owner of the construct
am ojectiv Se contacting with
limnsed croons ors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. $.00 ASSESSORS PARCEL NO.
and Professions property who
builds
larrow Law does not apply
to tr owner of Property who builds ur improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contacts for such projects with a cuntramon s)licensed pursuant to
the Contactors Licmise Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCELND-
❑ l am exempt under See. ,BARC.for this WATER HEATER W/VENT 4.00 L G )
Basun
Owner Dam WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSA'I ION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby infirm that I have a certificate of consenl to sq Pp E, ZONING ENG.SITE NO.
or a certificate of Workerti Compensation Ins ence,or u e lifad
copy the afft�j�/�{/kkBBD.0003' HC.I. /1/ / /I
coney No.,IT
er'l ny a 111) 1-�
❑ Cert led copy is here�v famished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is RIJJWill, the city inspection division. MISC.- REFER TO ORD- Y N v N
p nnpncam /L i ❑ ❑ ❑ ❑
CC f,I'.R'I'I FI F li%IoM I'IION I°EDM WORKERS' PERMIT ISSUANCE 6.00 / . FLOOD ZONE A.LU C.
UJ > COMITNSAiION INSURANCE: PLG.CONTE. LIC.NO.�7E ( PLG. /I('PY C] N❑ Y E] NE]
'
his section need not be completed if the permit is for one ( TOTAL (/r
hundred dollars(8100)or Iess.l
U O 1 certify Owl in the purfnrr anae of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,] shill]not employ any person in any manner su as to
U hecona subject In the Worker+,''Compun.mtion Laws of California.
ED D2lc Appb°ant ALTER OR ADD TO MECH. q,OQ BUILDING
} to NO"I'ICE 'I0 APPLICANT': If,after making this Certificate of lix-
F 2 emplion,you should become subject to the Workers Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Cade, you ams( forthwiDu comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=11F.M.) 3.00
CONs'IRUCI ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I 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,Civ.C.). 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 ceNity thin 1 have read this Tpp[icallon and state that lite above VENTILATION FAN (SINGLE) 3.00 /
information is correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws relating to building construction, and
j hereby authorize representatives ec this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
abovehereby
authonedrize
properly for insp of
purposes.
(We) agree to save, indemnify and keep harmless Due City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may W anyw y accrue against said City in consequence of the PERMIT ISSUANCE 3.00
granting oflh' ENI. MECH.CONT. LIG NO. MECH.
/) TOTAL TOTAL
Si are
EPA dlllicant/Contractor Date
// - INSPECTOR COPY