7137 (2) - .AOPLICANT TO FILL IN IN RMATION WITHIN RED LINES -,U*ALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI ION r PERMIT NUMBER
-I- BUILDING APPLICATION &'PERMIT
ADDRESS
• S t SA-N LE#Aloto F BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 7137
OWNEB'S - PLAN CHECK VALIDATION
' NAME OTV. ELECTRIC PERMIT FEE
D�lFf rPHONE '
�i NAMERAcroR's - OUTLETS-SWITCHES-'RECEP 5.00/1.00
mrSC 0 ill ruc.NO• On.S`3� LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S - PPLIANCES-RESIDENTIAL 4.00 '
/I ADDRESS' p/
'V 1- NE,,250-6`91% PANELS - 5.00 - DATE OF APPLICATION
ARCHITECT PLAN-CHECK P.C.NO.
OR SIGNS '6.00 -„
ENGINEER -
LIC.NO. SIGNS TRANS. . 3.00 -
ADDRESSErvG. SPECIALCIRCUIT 'S.DD PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00 -
Boo ss Ts ` , MOTORS SEE FEE SCH.
SERVICE CHANGE - 10.00 (Ac.�
0 0 0 LICENSED CONTRACTORS DECLARATION
AN' 2 I�j Y�'I
u rue f.
a I hereby affirm that I am licensed under provisions of Chapter 9 - ISS DATE
N a w (commencing with Section 7000)of Division 3.f the Business and 1 PLG. MECH.
r y z Professions Coll• n_dX�,'Iceine is m full for anJ Sfs O ❑ ❑
z O o— License Class Lic.Number C10 -
o w r o Date Contractor 4 Ave
a m f BUILDING PERMIT
rc rc w u ` OWNER-BUILDER DECLARATION INFORMATION
F
D ID N 1 hereby affirm that I am exempt from the Contractor's License MISC.— REFER TO ORD
F u m j Law for the following reason.(Sea 7031.5,Business and Professions PERMIT ISSUANCE 6.00 VALUATION $/FT.
Code:Any city or county which requires a permit to construct,alter,
It 4 o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
a w m u requires the applicant for such-permit to file a signed statement that TOTAL .-'y ' PER TO
he is licensed pursuant to the provisions of the Contractor's License , •�
F i a
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe M
4 D Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
Mthe the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
N ; -o by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4:00
of not more than five hundred dollars($5000.): _
❑ Las owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE •2.00 -oce.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 ACR EAGE
himself or through his own employees,provided that such improve- _
merits are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) ;100 BUILDING USE
builder will have the burden of proving that he did not build or int- . 'RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20,00
❑ 1,as owner,of the property,am exclusively contracting withEl El EJ El 1:1
'licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-�l'INC 5 V.B. 5.00 ASSESSORSPARCEL 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 contractors)licensed pursuant to -
theContractor'sLicenseLaw. s SEWER-SANITARY-STORM EA:200ft/8.00 TRACT NO. PARCEL NO.
❑ ['am exempt under Sec. ,B&P.C..for this WATER HEATER W/VENT 4.00
reason
Owner '- Date WATER SYSTEM. 4.00 ACC.DATE ACC.FILE NO.
WORKFRS'COMPIFNSATION DECLARATION .WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certifiedZONING ENG.SITE NO:
copy thereof(Sec.3800,Lab.C.). -
Policy co. Company
Q ❑ Certified c y is hereby furnished. FIRE SPRINK �ENERGV T-14,
z Z. Certified y s filed- ith the (y inspection division.
O Adplicanl- -1� yH MISC- REFER TO ORD. yE NE yo N�
' ~ w PERMIT ISSUANCE 6.00
LU CER TIF ICATEONSATIO' ON FROMWORKE RS' FLOOD ZONE A.L.U.C.
W �� COMPENSATION INSURANCE PLG.CONTR, LIC.NO. PLG.
(L a ('This section need not be completed if the permit is for one _ TOTAL Y NE] Y N[]
=) Z hundred do11arS($100)or less.)
L) O I certify that in the performance of the work for which this per, r FEE SUMMARY
ILL0 F mit is issued,I shall not employ any person in any manneror is to
CITY. MECHA PERMIT FEE
O W become subject to the Wlicant'Compensation Laws of California. - BUILDING
NOT Applicant ALTER OR ADD TO MEC '., 4,00
F. rail NOTICE TO APPLICANT: If,subject
making this Certificate sa Ex-
- 2 emptio n you should become Co subject to the Workers'Compensation. APPLIANCE 4.00 PLAN CHECK
provisions,io she Labor Code, you most forthwith comply with 'FEE
U such provisions or this permit shall be deemed revoked. AIR HANOLI 1 (TO 10 M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING GF.M.I 5.00 SEISMIC FEE
-1 hereby affirm that _there is a construction lending agency for EXHAUST HO ITH DUCT) 2.00
- the performance of the'work,for which this permit is issued(Sec. 'MICROFILM
3097,Civ.C.L - HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lenders Address ',ELECTRIC
Icertify that lhave read this application and state that the above VENTILATION FAN (SINGLE) 3.00 -
in formation is c&rect. I agree to comply with all city and county - PLUMBING
ordinances and state laws,relating do building construction, and BOILER-COMP(3 H.P.OP 100,000 B.T.U.) 4.00
•' ,.hereby authorize representatives of this city to enter upon-the BOILER-COMP (Over 100,000BTUISEE FEESCH. •MECHANICAL
above-mentioned'property for inspection,purposes.
(We) agree to save,'indemnify and keep harmless tire City of MISC.- REFER TO ORD. _
Cupertino against liabilities,judgments, costs and expenses.which PERMIT ISSUANCE. 3.00 — CONST.TAX,
ma ., any way accone against said City in consequence of the
gr ng of this permit '- MECH.CONT. LIG NO. MECH.
\ + // �C�Y+� -'7 /�•D S TOTAL d1� TOTAL
-y'\ /• $ignalur�of Applic Contractor Date
.. - OFFICECOPV - - .