6730 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES = USE BALL POINT PEN ONLY -
BUILDING PROJECT IDENTIFICATION r PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS BUILDING—ELECTRICAL—PLUMBING—MECHANICALD72D 6730
OVRNER'5 PLAN CHECK VALIDATION
NAME / J5. ELECTRIC PERMIT FEECONT _
• -I
caoRs
NAME UTLETS-SWITCHES-RECEP 5.00/1.00
NAME
.No. LIGHTING FIXTURES 5.00/1.00 r�
CONTRACTOR'S /raj PPLIANCES-RESIDENTIAL 4.00
AooREss
F ^ vRON PANELS 5.GO DATE OF APPLICATION
ARrHLILCT SIGNS 6 PLAN CHECK FEE P.C.NO. -
OR
ENGINEER
LIC.NO, SIGNS TRANS. 3.00
ARCHESSH OR ENG SPECIALCIRCUIT 55.00 PERMIT.VALIDATION -
ZIP EMP.METER OR POLE INS.- 115.00
AmucANrs MOTORS SEE FEE SCH. '
ADDRESS
SERVICE CHANGE 10.00
wO O LICENSED CONTRACTORS DECLARATION �7V�f
¢u v I hereby affirm that 1 am licensed under provisions of Chapter 9 NOV 2 — �J if�t ISRUAN
G a a (commencing with Section 70110)of Division 3 or the Businessend PEGG. ELECT. PL MECH.
H m i Professions Code,and my license is in full home and effect.
I o n License Class Lic.Number
o „ Dam CDnlraelur City of.Cupertino CPCD
BUILDING'PERMIT
¢ ¢re¢ OWNER-BUILDER DECLARATION I RMATION
AOa-ea MISC.— REFER TO ORD
w ; B.y 1 hereby olio that 1 um exempt from the Contractor'sfe cone VALUATION HLL0 < Lew for the following mason. 70715,Butinussand Professions - PERMIT ISSUANCE 6.00 ;
Code:Anycityor<uunly which msluiresapermittoaonslrcL al(cq' 9�Lo
BE
so¢ 2 'improve,dcmulish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NQ $LEC.
a, requires the applicant for such permit to file signed statement(hat TOTAL PERMIT TO (m/�('jC 7
wkis licensed pursuant to the provisions of the Contractor's License
H z Q Law(Chapter 9(cummerems.ith Sccriot 7000).f Division 3ofthe
Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE t—N
¢ r $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
B. by any applicant for a permit subjects the applicant toa civil penalty gLTER-DRAIN&VENT-WATER (EA.) 4,00
of nor more than five lwndred dollars(S500)J'.
❑ I,as owner of the properly,or my employees with wages as BACK F LOW PROTECT.DEVICE 2.00 DEC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure u not
intended or offered for In(Sec. 7044, Business and ProfrnieB, DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT,FLOOR AREA TOTAL ACREAGE
. himself or(hmogh his own employees,provided that such improve-
GAS 4.00
mentsamnot intended oroffered for sak.If,however,the building
or m provemenl is sold within one year of completion,the owner GAS-EASYSTEM-OVER 4 IEA) 100 BUILDING USE
builder will have the burden of proving that he did not build o; . . .
am- RES IND CON PB Omer
move for Propose of sale.l. INDUSTRIAL WASTE INTER. 20.00
❑ 1,v owner of the property,um exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to cle,noct Ore project(Sec.7044,Business LAWN SPR INKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor i License Law dens not apply
to an owner of progeny who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
Contracts fur such projects with a contracbmBS)licensed pursuant to
the Contractor's License law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL No.
I exempt r ec. B. .C.furtno WATER HEATER W/VENT 4.00
rea�ulTJSJ7�T ..
OIW^^ fir— WATER SYSTEM - 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSAI'ION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a ttrli ficate ofconsent to self-insure.
or a certificate of Workeri Compcnvtion Insurance,or v certified ZONING ENG.SITE NO.
Copy lhereof(Sec.3800,Lab.C.). '
Policy No. Company -
O /, „❑ Certified copy is hereby hunisl®d.. FIRE SPRINK ENERGY T 24
Z 77Y '❑ Cenifed copy is filed with the city inspeeliun division.. MISC.- REFER TO ORD.
O Applicant - Y ❑ N[JV E] NEI
cERTI FICATE OF EXEMP F16N FROM WORKERS' PERMIT ISSUANCE 6.00 FIL OZONE A.L.U.C.
W COMPENSATION INSURANCE. PLG.CONTR. ❑C.140 PLG. N Y N
CL
O (This section need not be, completed if the Permit is for one TOTAL ❑ ❑ ❑ ❑
Z hundred do11um($100)or loss I
U 01 1 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 `
U. 'become subject to tire Workeri Compenmtion Laws of California. / 7
U LU Dam Applicant ALTER OR ADD TO MECH, q,Op BUILDING 6. a`
} run NOTICE TO APPLICANT: If,after making this Certificate of Iix-
? emption,you should become subject to the Workers'Compenmtion APPLIANCE a 4.00 PLAN CHECK !i, S2—
provisions of the Labor Code, you mosl•forthwith comply with FEE
.0 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.D0
' CONSTRUCTION uirvolrvc AGENCYAIR HANDLING UNIT(OVER 10MOCEM) 5.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work Iix which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's AddHEATING UNIT(OVER 100,000 B.T.U.P.50 ELECTRIC � � 61'0
ress
r
I mrtily that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information n correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP I3 H.P.Or 100,000 B.T.U) 4.00
hereby authorize representatives of this city to entcr'upon the BOILER-COMP (Over 100.000BTU)SEEFEESCH. MECHANICAL
above-mentioned properly 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 PERMIT ISSUANCE 3,00 CONST.TAX
. may i any.;way accrue against said City in coruequence of the
of this MECH.CONT. LIC.NO. - MECH.
TOTAL. TOTAL
•�, .Sign rcrf Applicant/Contractor Xutc -
OFFICECOPY