7249 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
BUILDING PROJECT IDENTI FICATION APPLICATION & PERMIT
ADDDING °} 7249
ADDRESS
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNE '5 PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
•' V 9,,nAPHONE
NO('M]ERACT Rs OUTLETS-SWITCHES-RECEP 5.00/1.00
\- 7 Ic.No. 3 LIGHTING FIXTURES 5.00/1.00
r,DNTRacroR's PPLIANCES-RESIDENTIAL 4,00
CONTRAC G
CSN PHONE p�� PANELS 5.66 DATE OF APPLICATION
ARCHITECT SIGNS 5,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRESS ENO SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
APPLICANT'SMOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00 �,c
o O o LICENSED CON'p RACTOftS DECLARATION /l j6r
< u U I hereby affirm that I um licensed under provisions of Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and
a n _ BLDG. ELECT. PLG. MECH.
H w m
i Poofcoion,a Cndc�, nd��myJiccnsc.is in Cull force m e Cc't. ❑ ❑ ❑ ❑
z o m - License vss LID.Naber 'S 3
2 z H w Date 1'n-%P SContmemr
Y s BUILDING PERMIT
ac w a OWNFR-BUILDFR DECLARATION INFORMATION
a0 MISC.- REFER TO ORD
w 3 LL y 1 hereby affirm thin I am exempt from the Contractor's License VALUATION $/FT.
� LLDa Law for the fallowing reason.(Sec.7031.5,Ouxinessand Professions PERMIT ISSUANCE 6.00
y0 Code:Any cityor county which requires a permit to construct alter,
rt ¢ a 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC,NO. ELEC.
so
- 0 S, requires the applicant for such permit to file a signed statement that TOTAL
n w he is licensed pursuant to the provisions of the Contractors License PERMIT TO
i Law(Chapter 9(commencing with Section 7000)ufDivision3ofthe �4eSG'
a- Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
at F p the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
u3� by any applicant for a permit subjects lire applicant tea civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(S500)J'.
❑ 1,as owner of the properly,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
we 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 Contractors License Law does nofapply to an owner of
property who builds or improves thereon,and,who docs such work FIXTURES-PER TRAP 4.66 (y G SO,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such ilnprove-
mensarenolintendeJorofferedforsale.H.however,the building J GAS-EA.SYSTEM-11NC.40UTLETS 4.00 5L
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 MD CON 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:fire Contractor's License Low docs not apply -
lo an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1,0_0
contracts for such projects with a contmetoos)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.2008/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,BAP.C.for this I WATER HEATER W/VENT 4.00 xf
reason
Owner Date WATER SYSTEM 4.00
ACC.DATE ACC.FILE NO.
WORKliRS'COMPI.NSATION DECLARATION WATER TREATING EQUIP. - 4.00
1 hereby affirm that 1 have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec_3800,LAC.). '
Policy No-(:...ppmy
O ❑ Certified ropy is hereby fumi,hed. FIRE SPRINK ENERGY T 24
Z ❑ CCUifird pop, is filed with the city inspection division. MISC.- REFER TO ORD.
❑ N❑ Y ❑ N❑
CC T CERTIFICATE OF EXEMPTION 17ROM WORKERS' PERMIT ISSUANCE 6.00 FLOODZONE A.L.u.L.
W > COh11'IiNSAT10N INSURANCE PLG.CONTR. LIC.No. PLG. ❑ ❑ ❑ ❑
CL U (This Section need not be completed if the permit is for one TOTAL Y N V N
J Z hundred dollars(5100)or less.)
U O I certify that in the perl'ammumen of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H not is issued,I shall not employ any person in any manner so as to
U become subject tD the Workers'C ' n La C' irorn'
U W 0. Date Applicant a ALTER OR ADD TO MECH. 4.00 BUILDING
} m NOTICE'f0 APPLICANT': If,Sher maki g This Certifica 'of lox-
F. Z emption,you should become subject to the Workers'Compensal ion 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
CONSIRUCI ION 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 HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct.1 agree to comply with all city and county PLUMBING
ordinances and slate laws relating to building construction, and BOILER-COIVP(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,OOOBTUISEE FEESCH. MECHANICAL
above mentioned properly 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 PERMIT ISSUANCE 3.00 CONST.TAX
,,toy in any way accrue against said City in consequence of the
gountiSf f is permit',/) O _ MECH.CONT. LIC.N0. MECH.
TOTAL TOTAL
Sure of Applica t/Contractor Date
INSPECTOR COPY