C 7259-APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
BU LDING PROJECT IDENTIFICATION
APPLICATION &PERMIT
PERMIT NUMBER
G
D
ADDRESS
ooREss
,G: �
BUILDING -ELECTRICAL- PLUMBING -MECHANICAL
7259
OwrvE 'S
NAME
,,.� vnoxE
.N -
'i':
� `ELECTRIC PERMIT : �FEE'�
PL ECK VALIDATION
corv7NAcaoRs
NAME
- SWITCHES -RECEP 5.00/1.00
OUTLETS
�IN-�/^T1C„ .uc No. (�
k.
LIGHTING FIXTURES 5.00I1.00
ADOTRAc7on'sDORE
PPLIANCES- RESIDENTIAL 4.00
PANELS 5.00
DATE OF APPLICATION
ARCHITECT
OR
ENGINEER ✓��-
1'1 Llc. xo
SIGNS 6.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH, OR ENG.
aODPE55O
SPECIAL CIRCUIT 5,00
PERMIT VALIDATION
r '
rrEMP. METER OR POLE INS. 15.00
�•/
2.nJp64QktQU_M
r
J
a� s
APPLICANT Sn/J//11
Ao 14.7a 6 ILc2 Y�-�/D
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
LICENSED CON" TRACTORS DECLARATION
I hcrcby,ulfirin Ihm I am licensed under rovieion,ol'Chapter 9
(commencing with Section 9000) of Division 3 of the Business and
Profcssioas (p ,dds� J�nyIp e, in full foI- a t.
License ClaJr�S-O X49Iic.Number�-7_ 1-4_1r.
Date Coal ... ur
ISSUANCE DATE
BLDG.
❑
ELECT. PLG. MECH.
❑ ❑ ❑
B DING;P,ERMIT,, %s-,4
atTa't�'ik�fv
OWNIi R-BUILDIiR DECLARATION
I hereby atirsn that 1 on excio t from the Contractors License
Law foray ity orcounlywhichle 7031.S,ermit I,, and contra, aians
u ...ra permit to construct, alter,
Code: Any city or county it any structure, its issuance, also
improve, demolish, or repair any structure, prior
MISC. - REFER TO ORD
'llViHf���,1n
7-',(/•1 Ol/
PERMIT ISSUANCE 6.00
ELEC. CONTR. LIC. NO. ELEC.
n that
requires the applicant Darafor such permit to file a signed Contractor's
he is licensed pursuant en the provisions of the 7000)fDivision License•
rpt Division o and the
Law (Chapter 9 (commencing with Section is exempt
Business and ProfessionsCode)or that he is exempt therefrom and
TOTAL
go
B
QTY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation of Section 7031.$
ALTER -DRAIN & VENT -WATER (EA.) 4.00
by any applicant for a permit subjects the applicant loa civil penalty
of not more than five hundred dollars (5500).):
O I, as owner of the property, or my mnployccs with wages as
their vole compensation, will do the work, and the structure Is not
BACK FLOW PROTECT. DEVICE 2.00
lice. GROUP
PES. UNITS
DRAINS -FLOOR, ROOF, AREA, 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
FIXTURES - PER TRAP 4.00
SO, FT. FLOOR AREA
TOTAL ACREAGE
himself or Iloough his own employees, provided that such improve-
meutsarealitintendedorofferedforsale,lf, however, the building
'GAS-EA.SYSTEM-11NC.40UTLETS 4.00
r improvement is Sold within one year OI'romNel ion, the owner-
builder will hoe the burden of proving that he did not build Or im-
prove for purpose of safe.).
❑ 1, as owner of the properly, am exclusively contracting with
. ..
GAS - EASYSTEM -OVER 4 (EA.) 100
BUILDING USE
HES IND CON PS Other
❑ ❑ ❑ ❑ - ❑
INDUSTRIAL WASTE INTER. 20.00
LAWN SPRINKLERS - 1 INC 5 V.B. 5.00
LAWN SPRINKLERS -OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code "I'he Cnnlmnor s License Law Joei no[ apply
to an owner of Property Who builds or improves thereon, and who
contracts for such projects with a contractons) licensed pursuant lU
the Contractors License Law.
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 4.00 -
❑ I am exmnpl under Sec. ,B.dtP.C, for oris
reason
Owner Date
WATER SYSTEM/ 4.00
;�
ACC. DATE
ACC. FILE NO.
WORK IiRS'COMPIiNSA'1'ION DECLARATION
WATER TREATING EQUIP, 4A0
1 hereby affirm that 1 have a certificate ofconsent loself-insure.
or a certificate of workers' Compensation Insurance, or a certified
Copy thereUll1 780 LAC.)
Policy No AlPany_(1_
❑ Certified copy is hereby l unti
AT Cerlf lied cop filed w' 115 "vision.
App�l'Cam _
),,.1 0:)
ZONING
ENG. SITE NO.
a.
no
FIRESPRINK
Y❑ N❑
ENERGY T.24
Y❑ N❑
MISC.- ORD.
CIi R'I'119C TE 01' EXEMPTION FROM WORKE RS'
PERMIT ISSUANCE O.W '
FLOOD ZONE
A.L.U.C.
PLO. CONTR. LIC. NO.
PLG. rJ7
TOTAL
COMPF:NSA'601,1 INSURANCE
("This section need nal be completed if tire permit is for one
Y ❑ N❑
Y ❑ N❑
_ - agsst warcN
bundreddollars($100) or levi.)
1 artily that in the person, of the work for which this per.
mit is issued. I shall nor employ any person in any manner So as to
QTY. -MECHANICAL PERMIT FEE
EFEE•SUMM
,ARY
!GYM
BUILDING
l�
become subject to the Workeri Compensation Laws of California.
Dare Applicant
NOTICE 10 APPLICANT: IL after making this Certificate of fix-
emption, you should become subject to the Worked Compensation
ALTER OR ADD TO MECH. 4.00
APPLIANCE 4.00
PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
such provisions or This permit shall M: deemed revoked.
FEE "
AIR HANDLING UNIT (TO 10p00CF.M.) 3.00
AIR HANDLING UNIT (OVER 10D]OC.F.M.) 5.00
SEISMIC FEE
tsa
CONSTRUCTION LENDING AGENCY
1 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.
EXHAUST HOOD (WITH DUCT) 2.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATING UNIT (OVER 100,000 B.T.U.P.50
ELECTRIC
Lender's Name
Lenders Add
dress
1 certify Iled I have read this application and stare that the above
information is correct. I agree to comply with all city and county
ordinmees and state laws relating to building construction, and
VENTILATION FAN (SINGLE) 3.00
PLUMBING
BOILER- COMP(3 H.P. or 100,000 B.T.U.) 4.00
BOILER -COMP (Osar, 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD.
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in an way accrue against s d City in conuquenee of the
CONST. TAX
PERMIT ISSUANCE 3.00
MECH. CONT. LIC. NO. MECH.
TOTAL
.' TOTAL
this' permit.
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Si azure of Ap tractor Date,
S,;;
OFFICE COPY
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