7130APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
eU1LDING PROJECT IDENTI FICA710N
APPLICATION & PERMIT
BUILDING — ELECTRICAL— PLUMBING -MECHANICAL
PERMIT NUMBER
1 30
7130
emlmrar,
Al �D •
owNEH'S I / - /�
R�✓(Y/r) V
PHONErail I
p:; ' k
t fl -,4r ELECTRICP,ERMIT%'
5.
PLAN CHECK VALIDATION
i CONTRACTORS
NAME
UTLETS -SWITCHES-RECEP 5.00/1.00
LIGHTING FIXTURES ,,,5.00/1.00
- sec. No.
CONTRACTOR S
ADDRESS
PPLIANCES- RESIDENTIAL 4.00
'PANELS 5.00
PHONE
DATE OF APPLICATION
ARCHITECTSIGNS
OR -
ENGINEER
LIC. No..
8.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCIr, OR
ADDRESS ENG.
ZIP
SPECIAL CIRCUIT 5.00
PERRM'IT VALIDATION
�`
TEMP. METER OR POLE INS. 15.00
APPLICANTS
ADDRESS
MOTORS, - SEE FEE SCH:
SERVICE CHANGE 10.00
'
l
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
License Class Lie. Number
ISSUANCE DATE
BLDG. ELECT.
❑ ❑
G.
MECH.
❑
-
Date Contractor
BU 11001NGJAER.MIT
'NNFORM TION
OWNER -BUILDER DECLARATION
I hereby affirm Ilia( 1 am exempt from the Conloctor4 License
Law for lire billowing reason. (Sec, 7031.5, Business and Professions
Code: Any city or county which requires a permit to construct, alter,
Improve, demolish, Or repair any Structure, prior t0 Its Issuance, also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
MISC.— REFER TO ORD -
PERMIT ISSUANCE 6.00
VALUATION S/FT.
'
ELEC. CONTR. - LIC. NO. ELEC.
TOTAL
MIT TO
Law (Chapter 9(commencing with Section 7000)of Division 3 offle
Business and Professions Code) ear that he is exempt Ihcrefrom and
the basis for the alleged exemption. Any violation of Section 7031.5
OTY, PLUMBING PERMIT .'FEET-
ST PIES
T7 CONSTR.
hyanyapplicanl for a permit subjects lire applicant to a civil penally
of not more than five hundred dollars($500)J:
ALTER -DRAIN -WATER IEA.14.00
❑ I, as owner of the property, or my employees with wages is
their Sale compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 4.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does nob apply to an owner of
FIXTURES - PER TRAP 4.00
SO. FT FLOOR AREA
70TALACREAGE
property who builds or improves thereon, and who does Such work
himself' or through his own employees, provided that such improver
mems are not intended or offered kit sale. If, however, the building
GAS-EA.SVSTEM-l1NC.4OUTLETS 4.00
or improvement is sold within one year of cmnpletion, the owner-
ill have the burden of proving that he did not build or me-
p purpose of sale.).
s ..net of,lhe property, am exclusively contracting with
6Y.10,re
GAS - EA. SYSTEM. OVER 4 (EA.) 1.00.
BUIL ING E
HES INp 0 PB Other
❑ ❑ / ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
Iiontactrs to construct the project (Sec. 7044, Business
Code: The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon, and who
LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 r
LAWN SPRINKLERS -OVER 5 (EA.) 1.00
ASSESSO CELNOssions
contracts for such projects wilh a contractor(s) licensed Pursuant ill
the Contractor's Licemse Law,
SEWER -SANITARY -STORM EA, 200ft/8.00
TRACT N .
PARCEL NO.
❑ 1u exempt under SA.—, 0.&P.C. for this
ren
WATER HEATER W/VENT 4.00
'Swaer _ Dam "efz�qi.
WATER SYSTEM 4.00
ACC.OATE
ACC. FILE NO.
WATER TREATING EQUIP. 4.00
KERS'COMPENSA' ON DECLARATION
1 hereby affirm that I have a certificate nfconsem to self -insure.
or a cerldicale of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
/
_
copy thervol fSvC 3900, Lab.C,1.
Policy No, Company
V
FIRESPRINK
y ❑ N ❑
ENERGYT-24
v N
❑ ❑
❑ Certified copy ishereby furnished,
Applicant Certified copy is fled with the city inspection division.
MISC. - REFER TO ORD.
att r0%CATE OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.L.U.C.
COMPENSATION INSURANCE
(fill, aetl6n need Ilet Ise completed if the permit is for one
hundred do0ars(SIOO)or les.l
I certify (hat in the performance of the work for which this per
mInlander�RY
it hs issued, I shall not employ any person in any Inlander so as to
Y ❑ N ❑
Y ❑ N❑
PLG. CONTE, LIC. No.
PLG.
IOTA
;
y, '
OTY: - • ' ;„h:' MECHANICAL PERMIT FEEj`
-
,lFEE,SUA
MM
BUILDING
became snhject 10 the Workers' Compensation Laws of California.
Date Applicant
'10
ALTER OR ADD TO MECH. - 4,00
NOTICE APPLICANT: If, after making this Certificate of Ex-
emption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you mus( forthwith comply with
such provisions or this permit shall be deemed revoked. -
APPLIANCE 4.00
PLAN CHECK
FEE
AIR HANDLING UNIT (TO 10MC.F.NL) 3.00
AIR HANDLING UNIT(OVER 10=C.EM.)5.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 2,00
the performance of the work tut which this permit is issued (Sec.
3097, Civ.CJ.
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address
HEATING UNIT 100,000 B.T.U.)7.50
ELECTRIC
I certify that l leave read this application'and state that the above
VENTILATIONFAN(SINGLE) 3.00
information*k correct. 1 agree to comply with all city and county
;ordinances and state laws relating to building construction, and
PLUMBING
BOILER-COMP(3 H.P. or 100,000 B.T.U.) 4.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH. -
MECHANICAL
'hereby autmrac representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(WO agree to vve, indemnify and keep harmless the City of
MISC. - REFER TO ORD.
Cupertino against liabilities, judgments, costs and expensex which
way accrue against sx'd City in consequence of,the
-
PERMIT ISSUANCE 3.00
_CONST. TAX
K,''permit
UY
JDate
MECH. CONT. LIG NO,
MECH.
TOTAL
'.
TOTAL
Vul
tea on actor
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OFFICE COPY