8594 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTIFICATI ON PERMIT NUMBER
Dc APPLICATION & PERMIT
A ����
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ADDRESS 7555 Barhhart BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNERS „ PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
City of CupertAW
NAMtERACToes UTLETS-SWITCHES-RECEP 10.00/1.00
LIC.NO. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.NO. SIGNS TRANS. 3.00
ADDRESS lima SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
APPLI MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
woo LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
M u u I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
m a N (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H m z Professions Code,and my license is in full Imce and effect. ❑ ❑ ❑ - ❑
O i In W License Class Lit.Number ,
Date Contractor
a x f - BUILDING PERMIT
Q o i < OWNfi K-B D1LDIiK DIiCLARA'fION INFORMATION
wS LL m 1 hereby affirm that I am esempt from the Contractor's License MISC.- REFER TO ORD VALUATION S/FT.
Fu04 Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
le to c p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
le
¢ requires the applicant for such permit to file a signed statement that TOTAL
w LL he is licensed pursuant to tin provisions of the Contractor's License PERMIT TO
H z r
Low(Chapter 9(commencing with Section 7000)of Division 3.1 the
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ Oo the basis for the alleged exemption.Any violation of Section 7031.5 STORIES PE CONSTR.
c ;m by any applicant for a permit subjects the applicant toacivil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more titan five hundred dollars(S5001.):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole 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. 5.00
Code:The Contractor's Lueffse Law does not apply to an owner of - -
prOpertyWhVbuilds or Improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE '
• himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,Bre owner- GAS-EASYSTEM-OVER 4 IEA) 200 BUILDING USE
-
builder will have the burden of proving that h . . .
e did not build or int- RES IND CON PB Other
prove for 1,.,o ser of sale). INDUSTRIAL WASTE INTER. 30.00 El ❑ El : ❑ ❑
❑ d as owner of the property.he exclusively contracting with
licensed colons Cod to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 Assessoas PARCEL NO.
and Professions property Contractors License Law Joos not apply
co an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects wish IT contractor,s)limned pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO, PARCEL NO.
❑ Ium exempt under Sec.-.BA P.C.for this WATER HEATER W/VENT 6.00
reason
Owner rity 0 4 no DaN`5 WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
M'ORKERS'COMPENSA1 ION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofcorsent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy(hereof(Sec 3800,Lab.C.).
Policy No. Company
O ❑ Certified Copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z 0 Applicant-_Certified copy is tiled with the city inspection Division. MISC.- REFER TO ORD. Y ❑ NE] Y ❑ NE]
CCN CERTIFICATE 01'EXEMPTION FROM N'ORKEKS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
Lu > COAIPENSAI'ION INSURANCE PLG.CONTR. LIC.NO. PLG.
d Y N v N�
❑ 1"oris section need not be completed if the permit is for one TOTAL
:D Z hundred dollars 1$1001 nr less)
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any person in any manner so as to
OW become subject to the Workers Compensation Laws of California. BUILDING
a Date Applicant - ALTER OR ADD TO MECH. 5.00
} w NO'IICE 10 APPLICANT: If,after making(his Certificate of Ex-
F. Z emption.you should become subject to the Workers'Compensation APPLIANCE 5.00 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.) 4.00
CONSTRUCTION I.17NOING AGENCY AIR HANDLING UNIT(OVER IOAOOC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(See. MICROFILM
3097,Civ.C.L HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Nano H EATI NG UNIT(OVER 100,000 B.T.U.19.50
Lender's Address ELECTRIC
I certify that I have read this application and SLID` ` "
the above VENTILATION FAN (SINGLE) 4,00
• 'information is correct. I 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.) 6.00
hereby authorize representatives of this city tD emu upon the
above-mentioned property for inspection purposes. BOILER-COMP (Over t00,o008TU)SEE FEE SCH. MECHANICAL
(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 10.00 CONST.TAX
may in any way aemon against said City in cons"'a, cc of the
granting of this ennil. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
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INSPECTOR COPY