7236APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATI ON
APPLICATION &PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
^ ^
ADDRESS
NAN[R'S ,
- PHON (
L 2VL �4`�`, y 21 i.,�, ,�
OTsV. 4vA y'eaxeELECTRICyPERMI�T $�${�;'FEE
Y. 4, h, x„'+aCi,. „'m. V, &"4�F.
os,
PLAN CHECK VALIDATION
-
,
DATE OF APPLICATION
c it mRS -
L. uc.N
UTLETS-SWITCHES-RECEP 55.00/1.00
LIGHTING FIXTURES ' 5.00/1,00
I N CTOR's
O s
9C PRD "
PPLIANCES- RESIDENTIAL 4.00
PANELS 5.00
ARCHITECT
OR
ENGINEER
LIC. No. '
SIGNS 6.00
PLAN CHECK .7FEE NO.
SIGNS TRANS. 3.00
ARCH. OR
ADDRESS ENG'
ZIP
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
ISSUANCE GATE
SLOG. ELECT. PLG. MECH.
❑ ❑ ❑
ITEMP. METER OR POLE INS. 15.00
,APPLICANT'S r
ADDRESS "..
'
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chhpler 9
(yononeyeing with Section 7000) of Division 3 o the Business and
Licfn-se Cis Cod 1 1 'CCn Li Is S Pith fV
License Clad _ - .Conti ct. r
Date � Cnmractor
OWNER -BUILDER DECLARATION
I hereby aHinn that Lom'exumpPfmm the Contractor's License
Lawforlhefollowingreason.(Sec. 7031.5, Businessand Professions
Code: Any city or county which requires a permit to construct, alter,
improve,'demolish, or repair any structure, prior tO its ixsyNmC,, also
requires the applicant for such permit to file a signed statement that-
he ,s licensed pursuant to the provisions of the Contractor's License
Late (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business, and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption Any violation of Section 7031.5r+s"
by ;my applicant for a permit subjects the applicant to a civil penally
afoot mare than five hundred dollars (5500).):
❑ I, as Owner of the property, or my employees with wages as
their sole' compensation, will do the"work,.und the structure is not
imended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does riot apply to an owner of
property who builds or improves lltereou, and who does such work
hryysell' or -through his own employees, Provided that such improve
rt encs arcnot intended or offered for sale. If, however, the building
or Improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or im-
Provcforpurposeofmled.
-O. 1, as owner of the property, um exclusively contracting with
contractors to construct the project (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply
to an owner of property who builds or improves thereon- and who
contracts for such projects will, a contmctods)1icensed pursuant to
the Contractor's License Luw,
❑ hum exmnpt under Sec. ,tl.&P;C. for this
reason
1
BUILDING R IT,
INyORMATI'ON
-
Maw
MISC. - REFER TO ORD
PERMIT ISSUANCE - 6.00
VALUATION
8/FT.
ELEC. CONTR. LIC, N0.
ELEC.
TOTAL
- P RMIT TO
/TORIES TYPE CONSTR.
GT)V@ 't a ~p5"v , PLUMBING'P.ERMIT sa '1i'� P, FEE --
ALTER -DRAIN -WATER (EA.14.00
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA,CON D. 4.00
FIXTURES - PER TRAP 4.00
,
GAS - EA. SYSTEM -11 NG.4 OUTLETS 4.00
50. FT. FLOOR AREA
TOTAL ACREAGE
GAS - EA. SYSTEM -OVER 4' (EA.) 1.00
B uaowG USE
IIIES IND CON PB Orne,
❑ I --r ❑ 1-1licensed
INDUSTRIAL WASTE INTER. 20.00
LAWN SPRINKLERS- 1 INC 55.00
ASSessoRS P1ARCEL No.
LAWN SPRINKLERS -OVER 5 (EA.), 1.00
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 4.00
Owner Date
WORK IiRS'COMPENSATION DECLARATIONWATER
1 hereby aflirm that I have a certificate of consent In self -insure,
or a certificate of Workers' Compensation Insurance, or a certified
copy thereof(Sce. 3860, Lab.C.).
Policy No. Company
WATER SYSTEM4.00
ACC. DATE
ACC. FILE NO.
TREATING EQUIP. 4.00
ZONING
'ENG. SITE NO.
-
C,
❑ CCrtilied copy is hereby furnished.
❑ Certified copy is filed with the city inspection division.
•Applicant
,
MISC. - REFER TO ORD.
FIRE SPRINK
Y [] NE]
ENERGY T 24
Y ❑ IN
CII RTI P I CATS O 17 Ii XEMPTION PROM WORKERS'
COMPENSATION INSURANCE
(This section need or he Completed if the permit is for one
hundred dollars(SI00) or less)
1 certify that In 0,e performance of the work for which this per -&
mil is issued, I shall not employ any person In any roamer so as to
become subject to the Workers' Compensation Laws of California.
NO]ICAN1: I
NO] ICI: TO AI'1'LICANI': If, uflcr making this Certificate n( Gx-
emplion, you should become subject to the Workers' Compensalion
provisions of [lie Labor Code, you must forthwitl, comply with
such provisions or this permit shall be deemed revoked.
CONSTRUCTIONLENDINCACENCY
I hereby affirm that there is a construction lending agency for
the performance of the work. for which this permit is issued (Sec.
3097, Civ.CJ.
Lender's Name
Lender's Address
I certify that I have read this application and state that the uhuve
'`'"'Gratio, is correct. I agree to comply with all city and county
anfes and stale laws relating to building construction, and
ht. • e oh authorize representatives of This city to enter upon the
above -e -mentioned properly tfor inspection purposes.
(We)agreeto save, indemnify and keep harmless the City of
Cry Pertino against liabilities, judgments, costs and expenses which
may in any way accrue against said City in consequence of the
grunting Of this permit.
PERMIT ISSUANCE 6.00101WFLOOD
ZONE
Y ❑ NE]
A.L.U.C.
Y _ NE]
PLG. CONTR, LIC. NO.
PLG,
TOTAL ✓
-
4,'v 'MECHANICAL4PE M EE'S
Aso s �, gF
:., nrCyq.,k.( ya -EE
?.Ah� ;5y��.FEEj,SUMMARV
BUILDING
ALTER OR ADD TO MECH. 4.00
APPLIANCE 4.00
AIR HANDLING UNIT (TO 10MC.F.M.) 3.00
PLAN CHECK
FEE
AIR HANDLING UNIT (OVER 10MOC.EM.). 5.00
SEISMIC FEE
- EXHAUST HOOD (WITH DUCT) 2.00
HEATING UNIT (TO 100,000 B.T.U.) 4.00
MICROFILM
HEAT] NG UN IT (OV ER 100,000 B.T.U.)7.50-
ELECTRIC
VENTILATION FAN (SINGLE) 3.00
PLUMBING
BOILER-COMP(3 H.P. Dr 100,000 B.tU.I 4.00
BOILER -COMP (Over 160,000 BTUI SEE FEE SCH.
MECHANICAL
MISC. - REFER TO ORD. -
PERMIT ISSUANCE 3.00
-
CONST. -TAX 't
,
MECH. CONT., LIC. NO.
MECH. )�.'t
rorAL
; .,TOTAL
S,goatum of Applicant/Contractor Date
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION &PERMIT
BUILDING - ELECTRICAL -PLUMBING -MECHANICAL
PERMIT NUMBER
7236
BUDI
ADRESSL Ess
OWNER$
PLAN CHECK VALIDATION
"A 11
PHONE -9,q' -71)V
TY. ELECTRIC PERMIT - 'FEE
NTR Tons
N E
C#
UTLETS-SWITCHES -RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
_I C. NO.
DATE OF APPLICATION
li(JNTEAbTOn7
Aooness
L PEON J
APPLIANCES -RESIDENTIAL 4.00
PANELS 5.00
ARCHITECTSIGNS
OR
ENGINEER
uc. No.
6.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH. ORENG
SPECIAL CIRCUIT 5.0Q
PERMIT VALIDATION
TEMP. METER OR POLE INS. 15.00
ZIP
A
ADDNE55 RESS
DU
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
LICENSED CON'fRACI'ORS DECLARATION
1 hereby affirm this 1 am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business arid
Professions Codr.,7..Q-m licvnaa is a full for -GDJ'e S C.�;
:Cha Lie. Number T ^v
ISSUANCE DATE
BLDG.
❑
ELECT.
❑
P G. MECH.
❑
Data
Data / -' Contractor
BUILDING P R IT
INFORMATION
_
OWNER -BUILDER DECLARATION
I hereby allinn That I an exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5, Businessand Professions
Code: Any city or county which requires permit loconstruct.aller,
improve, demolish, or repair any structure, prior to its issuance, also
MISC.- REFERTO ORD
VALUATION
$/FT.
PERMIT ISSUANCE 6.00
ELEC. CONTR. LIC. NO.
ELEC.
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contmdoi s License
TOTALP
RMIT TO
CITY. PLUMBING PERMIT FEE
Law (Chapter 9 (commencing with Section 7000)of Division 3 of the
Business and Pudessions Codes or that he isexempt therefrom and
ORI S
vPE CONSTR.
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars (8500).):
ALTER -DRAIN & VENT -WATER (EA.) 4.00
❑ 1, as owner of the property, or my employees h wage's as
their Sole compensation, will do the work, and the st metum is not
BACK FLOW PROTECT. DEVICE 2,00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AR EA, COND. 4.00
intended or offered for sale (See. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve
mans are not intended or offered for sale. It, however, the building
FIXTURES - PER TRAP 4.00
SD. FT. FLOOR AREA
TOTAL ACREAGE
GAS- EA. SYSTEM- 1 INC.4 OUTLETS 4.00
or voprovement is sold within one year of completion. the owner-
builder will have the burden of proving that he did not build or im-
for purpose of sale.).
❑ I, as owner of the property, an exclusively contracting with
GAS - EA. SYSTEM -OVER 4 IEA.) 1.00
-
BUILDING USE ,
R B IND CON PB Cube,
❑ ❑ 13. ❑
INDUSTRIAL WASTE INTER. 20.00
LAWN SPRINKLERS - 1 INC 5 V.B. 5.00
licensed comracum, to construct the project (Sec. 7044, Business
and Pmfcssions Cudc: The Con Honor's License Law does nos apply
to an owner of property who builds or improves thereon, and who
ASSESSORS PARCEL NO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
Contracts for such projects with it contructods) licensed pursuant to
the Comractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
❑ 1 an, exempt under Sec. ,B.&P.C. for this
son
WATER HEATER W/VENT 4.00
Owner Date
WATER SYSTEM 4,00
ACC. DATE
ACC. FILE NO.
W'ORKERS'COMPEN'SATION DECLARATION
WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate ofconsent to self -insure.
or a Certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy Ihcrcof(Scc. 3800, Lh,C.).
Policy No,Company
FIRE SPRINK
Y ❑ N ❑
ENERGY T-24
❑ V N ❑
❑ Certified copy ishereby furnished.
❑ Certified copy is fled with the city inspection division.
Applicant
MISC. - REFER TO ORD.
CER7t FICA'I'1-1 OF I?XI*MPfION PROM WORKERS
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.L.U.C.
PLG. CONTR. LIC. N0.PLG.
TOTAL 4
COMPENSA'T'ION INSURANCE
CI his section need not he completed if the permit is I'or one
v ❑ N ❑
Y ❑ N ❑
OTY. MECHANICAL PERMIT FEE
FEE SUMMARY
hundred dollars IS 100) or less.)
I certify that in the performance of the work for which this per-
mit is issued, I ,droll not employ any Person in any manner so as to
BUILDING
become subject to the Workers' C'ompensatinn Laws of Calitonhia.
Dam Applicant
ALTER OR ADD TO MECH. 4.00
NOTICE TO APPLCAN'I': IC after making this Certificate of Ex-
emption, you should become subject to the Workers' Compensation
APPLIANCE 4.00
PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
FEE '
AIR HANDLING UNIT (TO 10,000GF.M.) 3.00
AIR HANDLING UNIT (OVER IQOOOC.F.M.) 5.00
SEISMIC FEE
CONST RUCf1ON LENDING AGENCY
1 hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 2.00
the performance of Thu work for which this permit is issued (Sec
3097, Civ.G),
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATING UNIT (OVER 100,000 B.T.U.)7.50
ELECTRIC
dcr'v Nae
Lm
Lenerder's Address
I certify that l have read this application and state that tl'abovc
VENTILATION PAN (SINGLE) 3.00
information is correct. 1 agree to comply with all city anJ county
ordinances and state laws relating to buildingconstruction, and
PLUMBING
BOILER- COIVP(3 H.P. or 100,000 B.T.U.) 4.00
BOILER -COMP (Over 100000BTU)SEEFEESCH.
MECHANICAL
hereby au0horiic representatives of this city to char upon the
ahovo-nrnnfioneJ Pnhperty for inspection purposes.
MISC. - REFER TO ORD.
(We) agree to save, interamly and keep harmless the City of
Cupertino against liabilities, judgments, costs :and expenses which
may in any way accrue against said City in consequence of the
CONST. TAX
PERMIT ISSUANCE 3.00
granting of this permit.
MECH. CONT. LIC. NO. MECH.
TOTAL
TOTAL
b,
Signature of Applicant/Contractor Date
INSPECTOR COPY