The URL can be used to link to this page

6257APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BU LDI NG PROJECT IDENTIFICATION APPLICATION & PERMIT BUILDING -ELECTRICAL -PLUMBING -MECHANICAL PERMIT NUMBER 6257 ING ��ff cs,o _e D_ V Lfd OWNER'S it �j/��J "AM ",/ e, OTY. ELECTRIC PERMIT FEE PLAN CHECK VALIDATION /� PHONE S/J UTLETS- SWITCHES -RECEP 5.00/1.00 (TCONTRACTOR /nL� r�/ 1,.. LIc.Nol DATE OF APPLICATION LIGHTING FIXTURES 5.00/1.00 CONT Ac R' A q o7 P ONE Z LIANCES- RESIDENTIAL 4.00 PA LS 5.00 rfE OROHIT/ SIGNS 6.00 PLAN CNECK FEE P.C. NO. SIGNST NS. 3.00 ENGINEER _ LIC. NO, ARCH.ENG. SPECIAL CI DIT 5.00 PERMIT VALIDATION EMP. METER POLE INS. 15.00 ZIP C / ADDRESS ADDRESS MOTORS '. SEE FEE SCH. SERVICE CHANGE 10.00 O •• LICENSED CONTRACTORS DECLARATION I hereby aflirm (far I em licensed under provisions of Cllapmr 9 (commencing with Section 7000) of Division 3 f h w nd Professions Code a nydlcenu is in full f, • a LicenseCWss_ 1100 Li,, ISSUANCE DATE BLDG. ❑ ELECT. I 0 PLG. MECH. El Uatc Conlmdor BUILDING PERMIT OWNER- UILDI'R UBCLAR 'ZION I hereby affirm that I am exempt from the Contmc�Lc Law for Ile following reason. (Sec. 7031.5, Business and Professions Code: Any city or county which reyuiresa permit tpeamstrucLafleq improve, demolish, or repair any structure, prior to its issuance, also INFORMATION MISC.- REFER TO OR PERMIT ISSUANCE 6.00 - VALUATION-TS/FT. ELEC. CONTE. LIC. NO. ELEC. requires the applicant for such permit to file a signed statement tet he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code) or that he is exempt therefrom and TOTAL PERMIT TO QTY. PLUMBING PERMIT FEE STORIES TYPE CONSTR, the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (3500).): A ALTER -DRAIN & VENT -WATER (EA.) 4.00 ❑ 1, as owner of lire property, or my employees with wages as their sole compensation, will do the work, and the structure is not BACK FLOW PROTECT. DEVICE 2.00 OCG GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA,COND. 4.00 intended or offered for sale (Sec. 7044, Business and Professions Code: The Conimclor's License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or through his own employees. provided that sudsimprove- mentsarelotintendedoa otfered forsale. If, however, the building FIXTURES - PER TRAP. 4.00 SO. FT. FLOOR AREA TOTALACREAGE GAS -EA. SYSTEM -1 INC. 4 OUTLETS 4.00 i or improventen Dis sold within one year of completion, the owner - builder will have the burden of proving thin he did not buildor inn- prove for purpose ofsale.). lu ❑ [,as owner of the property, am exclusively contracting will) GA5 - EA. SYSTEM -OVER 4 (EA.) 1.00 BUILDING USE EES IND CON PIT Omer ❑ ❑ ❑ ❑ ❑ - INDUSTRIAL WASTE INTER. 4000 licensed contractors to construct the project (Sr, 7044, Business and Professions Code: fire Contractor's License Law does not apply to air owner of property who builds or improves thercon. and who LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 LAWN SPRINKLERS - OVER 5(EA.) 1.00 ASSESSORS PARCEL NO. contracts for such projects with a contractor(%) IICCI1wd poramnt t0 the Contraclnr License Law, SEWER -SANITARY- EA. 200ft/8.00 TRACT NO. PARCEL NO. ❑ l antercempt under Sec. ,B.&P.C. for this reason ACC. DATE AGE. FILE No. WATER HEATER W/VENT 4.00 Owncr Date WATER SYSTEM 4.00 WATER TREATING EQUIP. 4.00 t �WORKFRS'COMPENSn'I'ION DECI.ARAIION I hereby affirm that I have a ceniticate of cun9mt to sell -insure. or a certificate of Workers' Co.... his Rat cc. or u S5cridied ZONING ENG. SITE NO. Zion Polly thereof ISec. 3800, Iah.C.l. ad Policy No. Com Puny !l��VV FIRE SPRINK Y ❑ N❑ ENERGV_T44 v ❑ N❑ ❑ Certified cOPy i,v hereby fo(nished. CcrOflud copy u I w,( ctl 1 livlslun. h ant mi sc. - REFER TO ORD. CER I IF v II I PROM WORKERS • PERMIT ISSUANCE 6.00 •00 FLOOD ZONE A.L.U.G. .CONTR //JJ LIC.N W L LG. TOTAL 111 F COMPIiNSn'I'[ON INSURANCIiP (This section need not be completed if the Permit is foe one V ❑ N❑ y ❑ No, hundred dollars (S I O(H of lell ) 1 certify that in the perfornim ce of the work for which this Per mit is issued, I shall not employ any perttm in any manner so as Is, QTY. MECHANICAL PERMIT FEE FEE SUMMARY BUILDING become subject to the Workers' Compensalio i Laws of California. Date Appllcanf NOTICE TO APPLICANT'. If, after making this Certificate of lis- ALTER OR -ADD TO MECH. 4.00 APPLIANCE 4.00 PLAN CHECK enlptlon, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. FEE AIR HANDLING UNIT (TO 10X0C.F.M.)- 3.00 AIR HANDLING UNIT (OVER IOAOOC.F.M.) 5.00 SEISMIC FEE CONSTRUCTION LENDING AGENCY I hereby uffinn that there is a construction lending agency for EX UST HOOD (WITH DUCT) 2.00 the performance o1IIIc work for which this permit is issued (Sec. 3097, Civ.C.). MICROFILM ' HEATI UNIT (TO 100,000 B.T.U.) 4.00 HEATINGU (OV ER 100,000B.T.U.)7.50 ELECTRIC Lenders Name Lender's Address IL'elrly tl181I M1Jvt`reJd IhIS Lppll[allOn'and til'JIf IIIJt tI1C a11oVe information is correct. I agree to comply with all city and county ordinances and stale laws relating to building construction, and VENTILATION (SINGLE) 3.00 PLUMBING pZr &V BOILER- COW (3 H.P.o 00,000 B.T.U.) 4.00 BOILER -COMP (Over 10O,W TUI SEE FEE SCH. MECHANICAL hereby authorize representatives of this city to enter upon Lite above-mentioned properly for inspection purposes. MISC. - R R TO ORD. (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses owhich may in any way accrue against said City in consequence IF the CONST. TAX PERMIT ISSUANCE 3.00 granting of this permit. MECH. CONT, UC. NO, M TOTA TOTAL Signature of Applicant/Contractor Date INSPECTOR COPY