C7257 APPLICANT TO MILL IN INFORMATION WITHIN RED LINES - USE BALLPOINT PEN ONLY
F' BU I LDINGPROJECTI ENTI FICATI ON 'PERMIT NUMBER
DDRESS APPLICATION & PERMIT
An �^��
DDnE55 v
BUfLDING-ELECTRICAL-PLUMBING-MECHANICAL G
O ER'5 PLAN CHECK VALIDATION
NAMB QTY, ELECTRIC PERMIT FEE
ICI 1.1rd 1 t I Ct'L1J PHONEryUV -I` I
�I CONTRACTOR. LETS-SWITCHES-RECEP 5.00/1.00 �0
NAME
1 LIC.No. TI
NG FIXTURES 5.00/1.00
ro TRAOmRS PPLIANCES-RESIDENTIAL 4,00
ADDRESS 1/
HONE y - PANELS 5.06 DATE OF APPLICATION
.RCHIIECI SIGNS6.06 PLAN CHECK FEE P.C.NO.
ENGINE
OR
LIC.No.
_400 K ` SIGNS TRANS. 3.00 PA
ARCH.OR ENG. PERMIT VALIDATION
Am SPECIALCIRCUIT I� 5.00
O _ Ve z,,Q461C) TEMP.METER OR POLE INS. 15.00 JUL
noosEUTs MOTORS C A SEE FEE SCH.
I - SG.SAM V0 Ip ^CI - - CIS) SERVICE CHANGE 10.00 City of Cupertino
w o o LICIiNS1iU CON'I'RAC'I'ORS I11iCLARA'I'ION /
Q u U I hereby uflonl (hat I :un IiwnaA under Prrvisinns of Chapter 9 ISSUANCE DAT
. 4 .,z "' (commencing with Section 7000)of Division 3 of the Business and
p B E& L MECH.
F w 1'n)fcssiure Cndc,anA my lirensc is in full I'D¢• I d gf-•ct ❑
e z O m License Clens I.ie.Number (
9 y w Late Cnntructor
BU LDING ERMIT
or w a OWNER-BUILDER DECLARATION INFORMATION
Aoa " MISC.- REFER TO ORD
X 3 LL r I hereby allirm that 1 sen ex Cm Pt Irom the Contractor's Licence VALUATION $/FT.
F u o a _ Law fur the following reason. 703 L5,Business and Professions PERMIT ISSUANCE 6.00 ^�^ ^M
Code:Any city or county which requires permit to construct,alter, ' /'A/
QQ¢Q Improve,demolish,or repair any structure,prior to Its Issuance,also ELEC.CONTR. LIC.NO. ELEC. pr1 Y"✓ r✓✓V a
iL O u requires the applicant For sued,permit to file a signed statement that TOTAL �5- PERMIT TO
a w es he is licensed pursuant to the provisions of the Contractors License
in Law(Chapter 9(commencing with Section 7000)of Division 3 of the /✓-/Jt
a Business and Prot'essions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
naT by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.14.00
of nm more Bhan five hundred doll...(55001.1:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not II
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Cade:The Contractor's License Law does not apply to an owner of
property who builds or improves Bin,and who dors such work FIXTURES-PER TRAP 4.00 SO.FT.E/Loon AREA TOTAL ACREAGE
himself re through his own employees,provided that such improve- 7�I
menus are art through
intended or offered ees,or pelf,howatsuhr building GAS-EA.SVSTEM-I INC.4 OUTLETS 4.00
pe Of improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of pmving that he did not build or ter- RES IND CO PB Omer
prove for purpose of sale.)' INDUSTRIAL WASTE INTER. 20.00 El ❑ ❑ El- ❑ [,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 - ASSESSO PARCEL NO.
and Professions Code: I lie Contractors License Law does not apply
to an owner of properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 � �
contracts for such projects with a contracturls)licensed pursuantto
the Contractors license Lew. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO, PARCEL NO..
❑ I:un exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 4.00
c'lou
Owm'r Date WATER SYSTEM 4.00 ACC.DATE ACC FILE NO.
WORK17RS'CONPBNSA'1']ON DECLARATION WATER TREATING EQUIP. 4.00
I hereby Alion that I have a ctrl ific:dc of rouse no to sell'-mLurc' ZONING ENG.SITE N0.
'mils"a of Workers'Cnmpensulinn Lusumnce,or u certified
r copy thereof(Sec.3800,Luh C.).
folie,Nn. Company
O. ❑ C lifed ropy'is he by I'Urpishcd. FIRE SPRINK ENERGY T 24
Z Z ' ificd. y is fl d wilt t c airy inspechol division.
O nplfcait �• MISC.- REFER TO ORD. Y❑ N❑ Y ❑ INC]
ir N' CH 'IEICA"Ili Oh EXEMM[ON FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
W CO,MPENSA'I'ION INSURANCE PLG.CONTR. LIC.NO. PLG.
0- 0 (This section need not he completed if the permit is for one TOTAL YE] N❑ Y ❑;r N❑
hundred dollars IS 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 F mit is issued.I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
O a DSH Applicant ALTER OR ADD TO MECH. -4.00 BUILDING
} to NOTICE '10 APPLICANT': If,after making this Certificate of Ex-
emption,you should become subject to the Workers'Compensation 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 10AOOC.F.M,) 3.00
CONS'YBUC1'ION LENDING-AGENCY AIR HANDLING UNIT(OVER 10 C.F.M.) 5.00 SEISMIC FEE -T
I herby affirm 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.). HEATING UNIT (TO 100,000 B.T.U.) 4.00
.andcr's Adore HEATING UNIT 100,000B.T.U.17.50 ELECTRIC 5 -
I-ender'.,Address
I. I cerify that I Ihave read thisapplicalion and scute then the above VENTILATION FAN (SINGLE) 3.00 -
information is correct. I agree to comply with all city and county PLUMBING �.
ordinances and state laws relating to buildingconsvuclion, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100000 BTU(SEE FEE SCH. MECHANICAL
above-ePcFiuned property for ins...court purposes.
`- (We) .gree to save, indemnify and keep harmless the Cil,of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
- may in any way accrue against said City in conscq Renee oC the
ming of this permit MECH.CONT. LIC.NO. MECH. �� �!]
I IT: 1 C k •� �n TOTAL TOTAL VVV
-in.L.I Lu.
Nognature,of APPIIcant/ ntrCu actor DatT
INSPECTOR COPY