7125 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENT[F I CATION PERMIT NUMBER
ADnLDINc Baa APPLICATION & PERMIT 7125
AUILVIN
U UILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME• PHONE QTY. ELECTRIC PERMIT FEE
corvTRncrmrs UTLETS-SWITCHES-RECEP 5.00/1.00
N ME
qfJ 7. LIC.No_VD ILIGHTING FIXTURES 5.00/1.00
CONTRACTORS 6) 0PPLIANCES-RESIDENTIAL 4.00
A0ODR 5 D Y
S G r P9 HONE S • PANELS 5.00 DATE OF APPLICATION
ARC ITECTSIGNS 6-00
ENGINEER PLANCHECK FEE P.C.NO.
on
LIC.NO. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5-� PERMIT VALIDATION
ADDRESS
Znv TEMP.METER OR POLE INS. 15.00 ���
APPLICANTS
ADDELSSMOTORS SEE FEE SCH.
URCss
_ SERVICE CHANGE 10.00 '•��
woo LICENSIiU CONTRACTORS UGCI-ARATION
v sus I hereby affirm Ilett I am licensed under provisions of Chapter') ISSUANCE DATE
Wz vw (commencing with Section 7000)of Division 3 of the Business and BLDG. ELEC PLG. MECH.
1•Hoz PR.I'cssions Code,and nny hccnsm ism full fume mW eDBct. ❑ ❑ ❑
o Lincnx,Class Lic.Number
tzo z T w Ua(c Cnnin[lor
cBUILDMJG PERMIT
re acw a OWNER-BUILDER DECLARATION INFORMATION
sone " MISC.- REFER TO ORD
3 LL y I hereby affirm that I am exempt from the Contractor's License VALUwTION
F LL o j Law far the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00
0 � Cock:Anycity orcounty which requiresa permit to construct,alter, ELEC.CONTR. LIC.NO.
Ec an 40 improve,demolish,or repair any stmcture,prior Ia its issuance,also ELEC.
O u requites the applicant for such permit to file a signed statement that TOT. / PERMIT TO
w. he is licensed pun ant to the provisions of the Contractor's License
Fit Law(ChalHer 9 leommencingwith Section 7000)of Division3ofthe
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ r oo the basis for the alleged exnnption.Any violation of Section 7031.5 STORI 5 lyVIEGUNSTH
;.2 by any applicant for a permit subjects the applicant o a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars($500).):
❑ 1,as owner of the property,m my employees wills wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
finer sole compensation,will do the work and the structure is not
intended nr offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA COND. 4.00
Code: Its Contractor's License Law don'not apply it)an owner of
property who builds or improves thercom 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-
ments are not intended or offered for sale.It.however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will Im,C the burden of proving that he did rent build or ire- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
/ ❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractmrs 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
tale C,contracts fnrsuchprnjetswith acontracmrls)lirenuA pursuant to SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
the Comrnor such
License Law.
❑ I am exempt under Sec,-,B&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner Unlc WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK I!RS'COMPENSA'IION OECI.ARATION WATER TREATING EQUIP. 4.00
I hurehy affirm thus I have a cerlificale of consent to self-losllre. ZONING
or a cv,lincute of Workers'Compunmlion Insurance.err a certified ENG.SITE NO,
copy thereof(Sc,3800,LabLJ.
policy No. Company
O �❑/ CertiI opy ix hereby/1"'i I'll FIRE SPRINK ENERGY T-24
z Z �p�CenI I•J copy file w th the oily spection division. MISC.- REFER TO ORD. y N y N
O Ap-ph ce cc ❑ ❑ ❑ ❑
P: va PERMIT ISSUANCE 6.00
� > CE lG\T' P F.'..1PTI(lN IBOAI WORKERS' FLOOD ZONE A.Lu.C.
Lu _ COMPF.N TIONINSURANCF PLO.CONTR. LIC.NO. PLG.
CL O (Phis section III not be completed if the permit is for one TOTAL Y❑ No , Y ❑ N❑
-D Z hundreddo11ars(S100)or less,)
U O 1 certify that in the pc,bereince of the work let which Ibis Ver- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mil in Issued.I shall not emplpy any person in any manner so as to
U bcconm sahjcct to tho Workers'Cnnspmamion Laws et Culifom.a
a U:Ue Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} SO NOTICE'10 APPLICANT: If,utter making phis Certificate of Es-
Z emPtion,you should become subject to the Workers'Compensutmn APPLIANCE 4.00 PLAN CHECK
provisions of the labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deetncsl revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.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
Lender's AddreHEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
ss
I certify that l have read this application and state that Dm above VENTILATION FAN (SINGLE) 3.00
S information is correct. 1 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
BOILER-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
may i any way accrue aa' t said Gity in ectsequ• ee of the PERMIT ISSUANCE 3.00
gran{ing of this permit. MECH.CONT. LIC.NO. MECH.
I TOTAL TOTAL f
Signa c ol'Applic t/C ac or Date 60
INSPECTOR COPY