7224 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
AOORcss//J� 0 TIFJ/L.l�HT �T. ( Z24
7 Q BUILDING-ELECTRICAL-PLUMBING-MECHANICAL q
CARRIER S PLAN CHECK VALIDATION
NAME TY. ELECTRIC PERMIT FEE
ECNAG PHONE o?�� ;L
CONTRACTORS UTLETS-SWITCHES-RECEP 5.00/1.00
�/ /�
64PAuc.No.Jeopo LIGHTING FIXTURES 5.00/1.00
CONTRACTOR Q NESTiUdT Sf. APPLIANCES-RESIDENTIAL 4.00
A E55
e ¢' / HONE p7 9- PANELS 5.06 DATE OF APPLICATION
ARCHITECT SIGNS 6,66 PLAN CHECK FEE P.C.NO.
OR
t ENGINEER
LIC.NO. SIGNS TRANS. 3.00
/ ABCR. ENG. PERMIT VALIDATION
ADDRESS
ss SPECIAL CIRCUIT 5.00
21P EMP.METER OR POLE INS. 15.00
,Ars MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00 r
woo LICENSIiD CON'IRACI'ORS DECLARA'f10N
I hereby affirm that I am licensed under provisions of Chapter') ISSUANCE DATE
(wmmuicgh ilh Section 7000)of Division 3 of the Business and
'F m Z.� Professmns Code,,,py��,,��pyy I"ucense is m full Torce ned , *e%"'�°- 4-:I - -- p- .`.•-- BO_jELE❑CT. -PL❑G.�, MECH.
z o w L1ccnsc Class L.�.�LicNumber 7�
o z H ow Dutc Contractor .
a r f BUILDING PERMIT
¢ ¢w OWNI'R-BUILDER DECLARATION INFORMATION
u01 MISC.- REFER TO ORD
w 3 I hereby affirm that I um exempt from the Contractor's License
VALUATION SIFT.
F LL o a Law for the hallowing reason.(Sec 7031.5,Businessand Professions PERMIT ISSUANCE 6.00
Code Any city Or county which requires a permit to construct,alter,
ErCE Q p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
-D BE requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
a w m hu is licensed pursuant to the provisions of the Contractor's License
H z i
Law(Chapter IT(Commencing with Section 7000)ofDivision 3 of the ME��
a Itusiness and Plofcasiuns Codej FT that he is exen.pt therefrom and QTY. PLUMBING PERMIT FEE
T Do STORIES TYPE CONSTR. -
¢ I- the basis fpr the alleged exemption.Any applicant
of Section malty ,
i ; r' by any applicant l'oru pemiil subjects the applicum loacivil penally ALTER-DRAIN&VENT-WATER (EA.) 4.00
ul net mos than live hundred doll.,,($500).1:
❑ I,as owner of Bin property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 occ.GROUP RES.UNITS
their sole com pensmion,will do the work,and the structure is not
. Rnded,or Offered for sale (Sea 7044, Business and P,oficsslons DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law docs not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 SO.FT FLOOR AREA TOTAL ACREAGE
• himself or through his own employees.provided that such in.pni
Rents are not intended or offered for sale.If.however.The building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner-
bGAS-EASYSTEM-OVER 4(EA) 100 BUILDING USE
uilder will have the burden of proving that he did not build or un . . .
RES IND CON PB Omer
prove for purpose ofsale.). :- INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sea.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:1'he 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 for such projects with a contractorfs)licensed pursuant to
the Contrnor's Lwoise Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I and exempt under Sec. ,I3.&P.C.I'or this WATER HEATER W/VENT 4;00
reason
owner Dote WATER SYSTEM 4.00 ACC.�DATE ACC.FILE NO.
s. WORKERS'COMPENSAIION DECLARATION - WATER.TREATING,EQUIP.'.+• 4.00
H. _
lmmbv at(irm that lhave uccrlilicutc nCcwl'sent to set f-ixnure, ZONING
cenificam of Workers'Co rihensution Insurmice,or u ce7tificcl ENG.SITE NO.
copy there, ..�
800 Lab C Lh A - '
,_.. .Pollen Nml/1L7 LS.Compcmy` 1FEiPBR11ZE $-
❑ Ce til led Copy is hereby to ui,lsd. I FIRE SPRINK ENERGY R24
z Z 0'C rt'ficdd//c1_�Y file III he IY nspucuon division. '
O Appbcan -I- Q -/ham MISC. REFER TO ORD. Y ❑ N❑ Y ❑ N❑
Mro CEREIVICAl7i OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOODZONE A.L.u,C.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. .}
d O (1 hisr'wctioo need not be completed if the permit is for one TOTAL ,I Y❑ N❑ Y ❑ N❑
:D Z hundred dollars IS 100)or less.)
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT r FEE FEE SUMMARY
U_ P mit is issued,I shall not employ any person in any manner so as to '
lacconm subject to the Workers Compensation Laws of California.
O ED - BUILDING
Q_ Dam Applicant ALTER OR ADD TO MECH. 4.00
} W NOTICE 'I'f) APPLICAN"f: If,after making this Certificate of Ex-
1. Z CRpTion,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
previsions of the Labor Codcryou must forthwith comply with FEE
U such provisions or this permit shall b-c'deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M,) 3.00
CONS'I'Ruc,rION LENDING AGENCY AIRHANDLING UNIT(OVER 10=C.EM.) 5.00 SEISMIC'F,EE
a
I hereby anccm that there k is r clinch t®Ilon mit is
agency for EXHAUST HOOD (WITH DUCT) 2.00
the .Ov.mance of the work for which this permit is issued(Sac. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
30`J7.CIv.am
LenAer'x e
Address HEATING UNIT(OVER 100,000 B.T.U.P.50
Lender's Ad /E LECTR I C
I certify Bml I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00 - -
information is correct. I agree to comply with all city and county PLUMBING '
Ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 4.00
.r hereby adhori/n representatives of this city to enter upon the BOILER-COMP (Over 100.000 BTU)SEE FEE SCH. MECHANICAL /s.0-V✓
above-mentioned property for inspection purposes.
(WU 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 ac a against said City in consequence of the PERMIT ISSUANCE 3.00
grant' f t "s Penn L MECH.CONT. LIC.NO. MECH.
RrJV //r9 TW AL O TOTAL
Signature ol'ApplicantlContractoul te r
INSPECTOR COPY