7253•
Q
ZZ
P O
CC -
UJ >
d 0
D Z
Uo
� l-
0
O lu
a
tat
F =
.+,
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
7253
BUILDING
A�+ 3� DDRESSeess -
10277
OWNER'S
PLAN CHECK VALIDATION
NAME
OTY. ELECTRIC PERMIT FEE
S PHONE
CONTRACTOR
NAME
NAME
UTLETS- SWITCHES -RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
x N, Llc. No. S
DATE OF APPLICATION
CONTRACTORS
ADy!D•RGE4SS t
1 1 H PHONE D
APPLIANCES - RESIDENTIAL 4.00
PANELS 5.00
ARCHITECTSIGNS
OR
ENGINEER
UC. Na.
g-QQ
PLAN CHECK FEE P.C. N0.
SIGNS TRANS. 3.00
ADDRESS Enc.
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
EMP. METER OR POLE INS. 15.00
ZIP
S
APPLICANT
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
,, �--
jy U
1.ICI!NSI!D CONTRACTORS DECLARA'I ION
I hereby affirm fhat I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions C°Je.�anA ccense is in full torte and e( t
License Class. ,arf, '° Lic. Number
ISSUANCE DATE
BLDG.
❑
ELECT.
❑
PLG.
�\
MECH.
❑
hale Contractor
�j
BUILDING PERMIT
OWNER -BUILDER DECLARATION
I hereby affirm that I um exempt from the Contractor's Licence
Law for to following reason. (See. 7031.5, liusinessand Professions
Code: Any city or county which structure permit toconseher,
improve, Jemnlish, or repair an}'sUucturc, prior to its issuance, also
requires the appliCapt for such permit to file a signed statement that
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
INFORMATION
MISC. - REFER TO ORD
VALUATION
$/FT.
PERMIT ISSUANCE 6.00
ELEC. CONTE. LIC. NO.
ELEC.
TOTAL
PERMIT TO
F%6 (-
OTY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
thebasis for the alleged exmnption. Any violation of Se,tw07031.5
by any applicum for a permit subjects the applicant to a civil penally
of not more than tivc hundred dollars ($500).1:
ALTER -DRAIN -WATER IEA-) 4.00
❑ I, as owner of the property, or Illy employees with wages as
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AR EA, COND. 4.00
intended or offered list sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon, and who does such work'�
F IXTURES - PER TRAP 4.00 Q `
SO. FT. ELOOR AREA
TOTAL ACREAGE
himself or through his own employees, provided that such imProve. mmns are not intended or offered for sale. IL however, the building
GAS - EA. SYSTEM -1 INC. 4 OUTLETS 4.00 474'��
or impravemmH is sold within one year of completion, the owner-
builder will have the burden of proving that h e did not build or inn.
ntstirep
prove 1, as owner with
❑ as owner nt the property, son exclusively
- .
IGAS EASYSTEM -OVER 4 IEA.) 1.00
BUILDING USE
RES IND CON PD Omer
❑ ❑ ❑ ❑ ❑
INDUSTRIALWASTE INTER. 20.00
. 7044c(ing
d Ihe project (Sec. 7044, Business
licensed contractors to he
and Professions Code: The Contractor's mv Law does not apply
improves
to an owner of property who builds or mproves thereon, and who
LAWN SPRINKLERS- 1 INC 5 V.B. 5.00
LAWN SPRINKLERS -OVER 5 (EA.) 7,00
ASSESSORS PARCEL NO.
contracts forsuch projms with acoltnctons) licensed pursuant to
the Contractor's License law.
SEWER -SANITARY -STORM EA. 200(1/8.00
TRACT NO.
PARCEL NO.
❑ lam exempt under Sec,-, B.&P.C. for this
reason
WATER HEATER W/VENT 4.00
Owner Date
WATER SYSTEM 4.00 '4,e-
ACC.DATE
ACG FILE NO.
WATER TREATING EQUIP. 4.00
WOR K ERS'CONiPI:NSA'I ION DECI.A RAT ION
I hereby otfino tel 1 have a cerlifcate of consent to self -insure,
or a certificate of Workers' CBmpensasion Insurance, or a cert ifcd
ZONING
ENG. SITE N0.
copy thereof (Sec. 3800, Lab C`).
Policy N'o. Company 4
❑ Certified copy is hereby Famished.
❑ Certified copy is filed with the city inspection division.
Applicant
FIRE SPRINK
Y ❑ N ❑
ENERGY TQC
I Y ❑ No
MISC.- REFER TO ORD.
CCR'IIFICA'1' C OF EXEMPfION FROM WORKERS'
PERMIT ISSUANCE 6.00 '�
FLOOD ZONE
A.L. U.C.
PLG. CONTE. LIC. NO.
PLG.
TOTAL
COMPENSATION INSURANCE
(ibis section need nut be completed if the permit is for one
v ❑ N❑
Y C] IN F]
hundred AolLus f5100) or tel I
I certify (hal in the performance of the work for which this per.
mil is issued, I shall nut employ any peon in any manner so as to
CITY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to the Workers' lion 1,!: f a' omiu._
Dal° Applicant
-
ALTER OR ADD TO MECH. 4.00
NO] ICI TO AI'1'LICAN'I': I1, after making Ibis Certificate of six.
eniplion, you should become subject to the Workers' Compensation
APPLIANCE 4.00
PLAN CHECK
provisions of the labor Code, you must lUr(hwitt comply with
such provisions ser this permit shall be deemed revoked
FEE
AIR HANDLING UNIT (TO 10SMC.F.M.) 3.00
AIR HANDLING UNIT(OVER 10=C.F.M.)5.00
SEISMIC FEE
CONSPRUCTION LI,NDING AGENCY
I hereby affirm that then is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued (Sec.
3097, Civ.C.L
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATING UN IT (OVER 100,000 B.T.U.)7.50
ELECTRIC
Lender's Name
Lender's Address
1 certify that I hove read fills upplicalim, and slate that the above
information is co... et. I rarer to comply with all city and county
ordinances and stale laws relating to building construction, and
VENTILATION FAN (SINGLE) 3.00
PLUMBING
G
BOILER H.P. or 100,0008.T.U.) 4.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD.
(we) agree m save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in an way accrue against said City in consequence of the
gra of Is permits"--
a
CONST. TAX
PERMIT ISSUANCE 3.00
MECH. CONT. - LIC. NO.
MECH.
OTAL
TOTAL
gnr�
INSPECTOR COPY