7074 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
` PERMIT NUMBER,
dBUILDING PROJECT"IDE= I I
BUILDING APPLICATION & PERMIT
-AO RE55
BUILDING7 O 7(1j
A
LIVQ =ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S
NAME '!, 1 T ¢ ♦ Y y( PLAN CHECK VALIDATION
• ��� ��� � DTYc rs1
NAME ncTaRs UTLETS-SWITCHES-RECEP 5.00/1.00
LIC.NO. LIGHTING FIXTURES 5.00/1.00
CONTRACTORs� • - ..
ADDRESS ppLIANCES-RESIDENTIAL 4.00.
PHONE PANELS - - 5.00 DATE OF APPLICATION
ogcHDEcr - SIGNS 8A0 PLANCHECKFEE P.C.NO.
ENGINEE
uc.x SIGNSTRANS., 3.00
ADDREss ENc. - , ". SPECIAL CIRCUIT' " '5.00 PERMIT VALIDATION
ZIP -TFEMP.METER OR POLE INS. 15.00 F
nooness Ts MOTORS SEE FEE'SCH.
1907 S. A(t
SJ1 y ` SERVICE CHANGE 10.00 v
�oo LI: 'Aa C-"
DECLARATION f�.FlIU //./3
, U. I hereby affnm that I am licensed under provisions of Chapter 9, _ -ISSUANCE DATE
a,Q m (commencing with Section 7000)of Division 3 of the Business and I I i BLDG. ELECT. PLG. MECH.
r h z Professions Code,and my license is in full force and effect. 1 I ❑ ❑ ❑ ❑
, 0.,- License Class Lic.Number
-
2 0 w Date Contractor
a >< F Cifv Of CUperfin I BUILDING.PERMIT-
a OWNER-BUILDER DECLARATION °Y
e o a o MISC.- REFER TO ORD - INFORMATION y+'x
w3 w a I hereby affirm that I no exempt from the Contractor's License VAWATION $/FT.
a. O a Law for the following reason.(Sec.7031.5,Businessand Professions
PERMIT ISSUANCE 6.00
f WEE Code:Any city Or County which requlfesa permit toconstruct,Jlleq
a o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTH. LIC.NO. ELEC.
A c LL requires the applicant for such permit to file a signed statement That TOTAL�/ PERMIT TO
w m he is licensed pursuant to the provisions of the Contractor's License - G
F z i Law(Chapter 9(commencing with Section 7000)of Division 3 of the - -
a Business and Professions Code)or that he isexempt therefrom and QTY. PLUMBING PERMIT FE'E'
the basis for the alleged exemption.Any violation of Section 7031.5 ' '' STORIES TYPE CONSTR.
i3: � by any applicant fora permit subjects the applicant toachuipenalty ALTER-DRAIN&VENT-WATER (EA.)'4.00 1 of not more than five hundred dollars($500).1:
U 1,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 the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 '
Code:The Conlraclar's,Licensc 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
himself or through his own employees,provided that such improve.
hientsmself a through
or employees,
ees,or provided
that however,the building GAS-EA:SVSTEM'-11NC.40UTLETS 4.00
Origin ovemenetnt is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
buer will have the burden of proving that he did not build or im- RES IND CON PB Omar
prpv_e 1,as ropurpose off the.)property, - INDUSTRIAL WASTE INTER. 20.00'
tJ�n Las owner of the tructhe exclusively. 7044,lins with ❑ ❑ ❑ ❑ ❑
lie sed contractors to construct the project La 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Cade:The who
builds o License Law does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS c OVER 5(EA.) 1.00
contracts for such projects with a cantradorf s)licensed pursuant to
the Conuaaor's License Law. SEWER-SANITARY-STORM EA.-200ft/5.00 TRACT NO, PARCEL NO.
'❑ tum exemr order Se ,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Owne , Dale WATER SYSTEM' 4.00 ACC.DATE ACC FILE N0.
WORKERS'COM4NSA1'ION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that 1 have a certificate ofconsenl to Self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sce.3800,Lab.CJ.
Policy No. -Company
-
0 ❑ Certified copy is hereby famished. FIRE SPRINK ENERGY T"20
_Z Z ❑ Certified copy is fled with the city inspection division. MISC. REFER TO ORD. v❑ t[0:) y
v ❑ No
O Applicant
rn PERMIT ISSUANCE 6.00 FLOOD ZOA.L.U.C.
cr - CERTIFICATE OF EXEMPTION FROM WORKERS'
IL > -COMPENSATION INSURANCE PLG.CONTR.' - LIC.NO. PLG,'
1 0 (This section need'not be completed if the portuit is for one TOTAL Y❑ ❑ N❑
Z) Z hundred dollars 1$100)or IcssJ -
U O 1 certify that in the performance of the work for which this per OTV3 MECHANICAL PERMIT' 'FEE FEE SUMMAR_Y i;,.,
LL F mit Is issued,1 shall not employ any person in any manner so as to 4 E; �,_s
W BUILDING
become subject to the Workers'Compensation Laws of California. -'
Date Applicant ALTER OR ADD TO MECH. 4.00
O
} N NOTICE'f0 APPLICANT: If,after making this Certificate of Ex-
F,. ? empfun,you should become subject to the Workeri Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
U, such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10MC.F.M.) 3.00
CONSTRUCTION LENDING AGBNCY - AIR HANDLING UNIT(OVER 101300C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a consiruclion 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 ELECTRIC
Lenders Addass
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 with all city and countyPLUMBING
ordinances and state laws relating
to building construction, and BOILER,-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly for inspection purposes.
(We) agree to save, indemnify and keep'hannless the City of MISC.- REFER TO ORD.
Cupertino against liabilities judgments, costs expenses which CONST.TAX
may in any way accru ga' i i nsequen Of
� PERMIT.ISSUANCE 3.00
ing o 's permi MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
azure o ApPlicanf7Contractor to
- OFFICECOPV '