C 7260 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION - - PERMIT NUMBER -
�', 9.ILDING APPLICATION & PERMIT ^ / /�
r ADORES. -10,700
IO,7oQ /� •V 7260-
1
-/C O
D� /SwZA BUILDING-ELECTRICAL-PLUMBING-MECHANICAL f GrVI
OwNEP'. "�i}" 's >,a• r¢' '( - . s '"'' - PLAN CHECK VALIDATION
NAME
�Ol)� G',NASE $EA•239� t'V +ELECTRICiFERMITkk ` ss ",FEE;.
t PHONE
NAMERAcrOR's UTLETS-SWITCHES-RECEP 5.00/100
LIC.NO, LIGHTING FIXTURES 5.00/1.00 ,
CONTRACTOR PPLIANCES-RESIDENTIAL .4.00
ADDS Ess
PHONE PANELS 5.00 - DATE OF APPLICATION
OR
ARCHITECT SIGNS 6.00 - PLAN CHECFEE P.C.NO.
ENGINEER '
' LIC.No. SIGNS TRANS. 3.00
nooREss ENG' _ SPECIAL CIRCUIT 5.00 /(5PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. - 15.00 ,
APPLI
AOORE5ANTS
5MOTORS SEE FEE SCH.
SERVICE CHANGE '.,10.00 � (a
,-Do LICENSED CONTRACTORS DECLARATION •1
a IS U I hereby affirm that I am licensed under provisions of Chapter 9 .Iw'B 14. 1+.�. ' ISSUANCE DATE
H Q H (commencing with Section 7000)of Division 3 of[lie Business and BLDG. ELECT. PLG. MECH.
H o z Professions Code,and my license is in full force and effect ❑ ❑ ❑ O
i o - License Class Lie.Number s
o w=w Date - Contractor L:i� CI C'u�ei IIO
¢ m ,BUIL"DING`PERMIT
¢¢ OWNER-BUILDER DECLARATION i� 'W,-` -+A^
g¢u,U `'n'a' "1aI�INFURMA1TIUN
wD a MISC.- REFER TO ORD
; u w I hereby aft irm that 1 am exempt from the Confmctor s License VALUATION - E/FT.
F =o J Law for the following reason.(Sec.703 1.5,Businessend Professions PERMIT ISSUANCE 6.00 '
Code:Any city.,county which requires a permit to construct,alter,
SE 2 ¢ p Improve,demolish,or repair any stuncturs,prior to Its issuance,also ELEC,CONTR. LIC.NO. ELEC. /
t]¢ requires the applicant for such permit to file a signed statement that TOTAL ICs PERMIT TO
w m" he is licensed pursuant to the provisions of the Contractor's License �•-
Hia Law(Chapter 9(commencing with Section 7000)of Division 3 of the °•'9;, u (Fy: s yj.# W GL�'G//
4 4 D Business and Professions Code)or that he is exempt therefrom and OTY: ) P,L`UMBING;PERMIT FEE
¢ $ the basis for the alleged exemption.Any violation of Section 7031.5 t+ ' a P ,.`<%'.x "i F T .-d STORIES TYPE CONSTR.
d5_ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00 '
of not more than five hundred dollars(5500).):
O 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 Contractor's 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
16
himself or through his own employees,provided that such improve-
ments are not
intended oroffered for sale.If,however,the building - GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
or improvement is sold 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 im- RES INDCON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER.' 20.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
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 `
contracts for such projects with a contractor(i)licensed pursuant to SEWER-SANITARY-STORM EA..200ft/8.00 TRACT NO. PARCEL NO.
the Contractor's Lice u I
ll exempt a ei Se ,BAPC.for this WATER HEATER A/VENT - • '4.00 `
.n
cr Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPF.NSATION DECLARATION WATER TREATING•EQUIP. 4.00
I hereby alfirm that I have a certificate ofconsent to wit-Ssurc,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,I.A.CJ. '
Policy No. Company
O ❑ Cevil'ied Copy is hereby f.unkled. FIRE SPRINK ENERGY T24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
p Applicant - Y❑ N❑ - Y C3 NL]
F- y PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU - CERTIFICATE OF COMPENSATION
FROM WORKERS'
W � ' COMPENSATION INSURANCIS - PLG.CONTR. LIC.rv0. - PLG.
a O (This xv�tim need not be completed if the permit is for one - TOTAL Y❑ N❑ Y❑ N❑
0 Z hundred dullars(SIO0)orless,)
U O I certify that in the performance of the work for which this per- 'QTY. §MECHANICAL,PERMIT'C'T t FEVFEE SUMMAy�`flVt
LL j- mit is issued.I shall not employ any person in any manner so as to +
U become subject to the Workers'Compensal ion Laws of California.
n Daic 'Applicant 2 ALTER OR ADD TO MECH. 4.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex- -
Z emption,you should become subject to the Workets Compensation 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
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 5.00 SEISMIC FEE
I hereby affirm that (here 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.CJ. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lendei s Name HEATING UNIT(OV ER 100,000 B.T.U.)
Lender's Address 1 ELECTRIC
Icertify that l have read thisapplieation and state that ilieabove 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
hereby authorize representatives of this city to enter upon the g01 LER-COMP (Over 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 '
in any way accrue agni st sail City in consequence•of the PERMIT ISSUANCE '3.00 3 -
"an of this p4mi. 1,- MECH.CONT. LIC.NO. TOTAL (�
_) !! i �1. - TOTAL,?" �7Uti
I re pplicon 'onlr c or ate
OFFICE COPY