7295 1 I& TO FILL IN INFORMATION ITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PRO41(ci IDENT KATION APPLICATION & PERMIT PERMIT NUMBER
"°""5° 7295
Ao //5� ILDING -ELECTRICAL-PLUMBING-MECHANICAL
PLAN CHECK VALIDATION
N E
ELECTRIC PERMIT FEE
PHONE
Nor ACTORS UTLETS-SWITCHES-RECEP 5.00/1.00
EIC_" LIGHTING FIXTURES 5.00/1.00
;O ACTOR' �� APPLIANCES-RESIDENTIAL 4.00
4
PROM PANELS 5.00 DATE OF APPLICATION
RCHUEC SIGN$. 6.00AZAPLAN CHECK FEE P,C.NO.
OR
ENGINEER
uc,NO, SIGNS TRANS. 3.00
ARCH.Os ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESzm rrEMP,METER OR POLE INS. 15.00
MOTORS SEE FEE SCH. S
A 55
SERVICE CHANGE 10.00
Foo LICIiN51iU ANI'RACT S DEChARA'I'ION
rt U v I hereby affirm that I um licensed under provisions of Chapter 9 ISSUANCE DATE
w (commencing with Section 7000)of Division 3 of the Business a BLDG. ELECT. PLG. MECH.
Nz Professions Code�yjJ�]�1license is in full force a
z o m - Licenx Cl s!dic �fJ-Lie.Number-
O m r Date Contractor
a m �(9,I BUILDING PERMIT
¢ e, w ¢ WN: UILDER DECLAR T O
O INFORMATION
a o ryMISC.- REFER TO ORD
w 3 LL m I hereby affirm That I am exempt from Ote Contractor i License VALUATION $/FT.
H cc 04 law for the following reason.(Sec 7031.5,Business and Professions PERMIT ISSUANCE 6.00
Code!Any city or county which requires a permit to construct,alter,
er u,¢ 2O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0, ELEC. 1
R:
LL requires the applicant for such permit to file a signed xinternal that TOTAL PERMIT TO
o he is licensed pursuant to the provisions of the Contractor's License /�{////`
z r
Law(Chapter7(commencing with Section 7000)Of Division 3 ofthe
a Business and Professions Cole)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ r o the basis for lite alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
A ;T by any applicant for a permit subjects the applicant loa civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employces with wages as BACK F LOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or ofl'cred for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Cod:The Contractor's License Law does not apply to an owner of ..
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP - 4.00 sa.FT FLOOR AREA TOTALACREAGE (
himself or through his own employees.provided that such improve- 1
merits are not intended or offered for sale.ll',however,the building GAS-EA.SYSTEM-I1NC-40UTLETS 4.00
or improvement is sod within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or ice- _ 0 IND CON PB Orher
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 ;�
❑ I,as owner of the property,am exclusively contracting withEl El
licensed contractors to construct the project(Sec 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
andProfessions Code:1lie Contractor's License Law does not apply
to an owner of property who builds Or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA,) 1.00
contracts for such projects with a contractods)licensed pursuant to
the Contractor's Licenx law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO, PARCEL NO.
❑ I au exempt Ruler Sec.-.It&P.C.lit this WATER HEATER W/VENT 4.00
reason
Ow"er Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE N
W'ORKERS'COMPENSAT ION DEj ARATION WATER TREATING EQUIP. 4.00
I hereby aHtrm that I have a certificate afe meat 1.self-in arc ZONING ENG.SITE NO.
or a certificate f Workers'Compenvtion s ranee,or a cc ifieJ -
copy the, 0.Lah.C.). /♦v/
I'micY No. 'o oh puny
citified copy.is hereh rnishe FIRE SPRINK ENERGY T 24
Z O A Cnnifi' op is I- with n i iy inspection division. MISC.- REFER TO ORD. v N v N�
Cc: N `CERI'I PI' TIS OI'IiXEMI'TION PROM W'ORRIiRS• PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.UX,
W J Cf1M1'IiNSATION INSURANCE PLG.CONTR. LIC.NO. PLG. Y N Y N
CL CL 0 1'f his section need not be completed if lite Permit is for one TOTAL
hundred dollars($100)Or less.)
U O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H out is issued, I shall not employ any person in any manner so as to
O become subject to the Workers'Compensation Laws of California. BUILDING
a Date-Applie°nl ALTER OR ADD TO MECH. 4.00
} N NONCE TO API'LICANI': If,after making this Ccrificatc of Ex-
FZ en,tion,you.ahoWd become subject to l he Workers'Compensatiao APPLIANCE 4.00 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 10,00DC.F.M.) 3.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10,0MC.F.M.) 5.00 SEISMIC FEE
I hereby affnrn that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM -
3097.Civ.C.). UEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
NHEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's NAddmame ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
• inlormatiou is correct. I agree tri comply with all city and county BOILER-COMP 13 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL 33 0`
ebove-mentioned property for inspection purposes.
(We) agree to Save, indemn' nd keep harmless the City of MISC.- REFER TO ORD.
Cupertino against ' !lilies, ' dgm nls,costs and expenses which CONST.TAX
may i4VApplicarilleffritrat
wa eruct a Inst �d City !n c sequence Of the PERMIT I DANCE 3.00
�nth! it. I J ME .CONT. IC,NO, T ETAL
/ TOTAL
lor aleLXO
INSPECTOR COPY