8593 t
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
PLICATION & PERMIT
uuILOINc AP
ADDRESS
7550 Delta Vnrgp - BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 8 5 v 3
OWNER'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
'HONE
NAME
NAMERA oRs UTLETS-SWITCHES-RECEP 10.00/1.00
L¢.NO. LIGHTING FIXTURES 10.00/1.00
ADoms PPLIANCES-RESIDENTIAL 4.00
CONTRACTORS
ADDRESS
PHONE PANELS 10.00 DATE OF APPLICATION
ARRCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
Lac.No, SIGNS TRANS. 3.00
ARCH Ess ervc. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 �r_I
w O O LICENSED CONTRACTORS DECLARATION TEMP,POLE 30.00
G o U0 1 hereby laf Orm that I am licensed order provisions of Chapter 9 ISSUANCE DATE
w z w (ttn
nmencing with Section 7000)of Division 3 of the Business and
G NBLD ELECT. PLG. MECH.
F N z Professions Cade,and my license is in full force and effect. ❑ ❑ ❑
Z O 9 - License Class Lic.Number
B m w Date.Contractor
a x ryBUILDING PERMIT
¢ ca OWN ER-BUI LDE R DECLA RA TION
A o s u INFORMATION
xi g LL y 1 hereby affirm that 1 am excniPt Goo tlic Comractor's License MISC.- REFER TO ORD
u O j Law for fire following reason.(Sec.7031.5,Businessland Professions VALUATION $/FT.
_ PERMIT ISSUANCE 10.00
Code:Any city or county which structure,
permit mconstruct,,also
Q improve,demolish,or repair any sUuc[nre,prior to its issuance,also ELEC.CONTR. - LIC^No ELEC.
.7s y LL requires the applicant for such permit to file'a signed statement that �` � TOTAL / PERMITTO
w m he is licensed pursuant to the Provisions of the Contractor's License
H z A Law(Chapter9(commencing with Section 7000)of Division 3 of the �.
4 O Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
the basis for the alleged exemption.Any violation ol'Secl ion]031.5 STO ES TVP NSTR.
Ate _ by any applicant for a permit subjects the applicant to a Civil penalty ALTER-DRAIN -WATERIEA.15.00
of not more than five hundred dollars(S500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4,00 OCC.GROUP RES.UNITS
their side compensation,will Ao Ole work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 1
Code:The Contractors License Law docs not apply to an owner of --I
,,.Perry who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SO.FT FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- -
met'
tsaye not intended oroffered for salC.If.however,the building GAS-EA.SYSTEM-1 1 NC.4 OUTLETS 6.00
or Improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 (EA.) 2.00
builder will have the burden of proving that lie did not build - . -
or im- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES IND CON Pa Omar
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project(See. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Codcproperty Contractor's s License Law does not apply -y
toan trowner ofpropertywho buildstrimproves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 s
contracts for such Projects with a contmetot sl licensed Pursuant in
,. the Contractor's License Law. SEWER-SANITARY-STORM EA.2001t/10.00 TRACT NO. PARCEL NO.
❑ Ino exempt under Sec.-,B&P.C,for Ibis WATER HEATER W/VENT 6.00
reason p��pp�
X Owner City 0€ Cupertino Date X7978 WATER SYSTEM 5.00 ACC.DATE ACC.FILE N0.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have.certificate of consent to self-insure. ZONING ENG.SITE N0.
or a certiGea¢of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
0 ❑ Certified copy is hereby fornished. FIRESPRINK ENERGVT"24
Z Z ❑ Certified copy is filed with the city inspection division. MISC- REFER TO ORD.
0 Applicant y❑ N y ❑ N❑
= T CERTIFICA'I'Ii OF EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W D COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLGCLa .
CL Z (This section need not be completed if the pennit is for one TOTAL y F] N❑ y ❑ N❑
hundred dollars(S 100)or less.)
U O 1 certify that in Om performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F Fill is issued,I shall nay employ any porsun in anY inunne(so as to
Ow become subject to tire Workers'Compensation Laws of California.
0. Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE"f0 APPLICANT: If,after making this Certificate of Ex-
F Z_ eniption,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 LENDING AGENCY AIR HANDLING UNIT(OVER 10000C.EM.) 6.00 SEISMIC FEE
1 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.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and slate that 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-OOMP(3 H.P.or 100;000 B.T.U.) 6.00
hereby authorize representatives of this city to niter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property 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 CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
granting of this permit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
PP scan e
INSPECTOR COPY