7280 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTIN CATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS ` _ /f
{✓.�� /"'�. /'( MUILDING-ELECTRICAL-PLUMBING-MECHANICAL 7280
OWNER'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
)�( PRONE
(;CNTRACTORS v OUTLETS-SWITCHES-RECEP 5.00/1.00
LIc,Nod7�� LIGHTING FIXTURES 5.00/1.00
CONTRACTORS
ss AcroFs -APPLIANCES-RESIDENTIAL 4.00
3
vROrve PANELS 5.00 DATE OF APPLICATION
ARCHIT CT PLAN CHECK FEE P.C.NO.
OR+clrvE£d' SIGNS 6.00
LIC,NO, SIGNS TRANS. 3.00
ARCIr�t ENG, SPECIAL CIRCUIT 5.00 PERMIT VALI1"'pgQ,
zIP ADD
EMP.METER OR POLE INS. 15.00 /M�
APPLICANT'S MOTORS SEE FEE SCH.
ADDRESS. MOTORS
SERVICE CHANGE 10.00'
0.00 0
O R z
FOO jz LICENSED CONTRACTORS DECLARATION City Of Cupertino
V a v I hereby aff rn that I am Hee nsed under provisions of Chapter 9 ISSUANCE DATE
m z i (coln..cre ng with Section 7000)of Division 3 of the Business and
F w 2 I r rf ssr Code and mplicenw is I full to
BLDG. E ECT. PLG. MECH.
Z,o w I¢Low.Classes 1.•'v L Number ❑ , ❑ ❑
O w Date-Z Contr9or 11..
^¢ Qw. .eOWN1,It-NUILDhR DLGI:ARATI N l'd:?. �1 - ---- _ - - - "'r- "�:.. _ r _ - rBUI DINGPERMIT
a o a U, - MISC.- REFER TO ORD y INFORMATION
w 3 I- 1 heu.by affirm that I am exenlpt from the Contractor. 1 IU.nsC
VALUATION $/FT.
r u o g I.Iw for the following reason.(See.7031.5,Business and l rolessons PERMIT ISSUANCE 6.00
ISO
Code:Any'Cityor county which requires a permit to construct,alter,
Qw improve demolish,or repair any structure,prior to its issuance,also EL CO R. LIC.NO. ELEC.
iE O IL requires the applicant for Sikh permit IO file a signed statement that TOTAL PERMIT TO
n w m he is,licensed pursuant to the provisions of the Contractor*%License "zlly
F z¢
Law:(Chapter 9(commencing with Section 7000)of Division 3 ofthe dV/
4 o Busiuess�aad Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
1-p the b 'hi for the alleged exemption.Any violation of Section 7031.5 STORIES ' TYPE CONSTR.
to by auyvnpplicant for a permit subjects the applicant o a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
,,feet...Coe than five hundred dollars(5500).):
❑ I,as owner of the property,or illy employees with wages as BACK FLOW PROTECT. DEVICE 2.00 Dcc.GROUP RES.UNITStheir sole compensation,will do the work,and the stn¢tmc I,not
intended or offered for sale(Sec. 7044, Business-ands Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Code:'file Contractor's License Law docs 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
himselfor through his own employees,provided that such improve- GAS-EA.SYSTEM-1 q.00
I Rtonts are not intended or offered for sale.If,however,the building
l or inlprovemcnt is sold within one year nl'completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING E
builder will have the burden of proving that he did not build Grim-
GAS
INDUSTRIAL WASTE INTER. 20.00 RES IND 0 RB Other
❑ 1,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 ASSESSOR RCEL NO.
and Professions Code:'I'he 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 contractorls)licensed pursuant to
the Convector,License Law. SEWER-SANITARY-STORM EA.200ft/6.00 TRACT NO. PARCEL NO.
❑ I am exempt Under Sec. ,B.&P.C.For this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.60 ACC.DATE ACC.FILE NO.
WORK IT RS'COMPENSA'IION DECLARATION WATER TREATING EQUIP. 4.00
I hereby alYrm that I have u certificate of consent to self-insure, ZONING
or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO.
copy thereof 3800, Df,.).
policy No.-Company
Q0' Certified ropy rshereby furnished. FIRE SPRINK ENERGY RT4
Z Z city inspection division. MISC.- REFER TO ORD.
O AppheunlT �• t v❑ N❑ V ❑ N❑
~ utPERMIT ISSUANCE s 6.00 - FLOOD ZONE A.L.u.c.
CC L.CliRTIPICATIi01'iEXI:MIrLION FROM WORKERS'
LOU �_ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
d o y(i his section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
D Z hundred dollars IS 100)or less.)
U O 1 cert ity that in the perl'ornlance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any person in any manner so as In
O w become subject to the Worker Compensation Laws of Calflorma. BUILDING
C. Date Applicant ALTER OR ADD TO MECH. 4.00
} to NO'I'ICE '10 APPLICANT: If,after making this Cenifiewe.f E..
F Z anplion,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 10p000.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby 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.L HEATINGUNIT(T0,100,0006.T.U.) 4.00 _
Lender's Name
NH EAT[NG U N IT(OV ER 100,000 B.T.U.)7.50
Lender'same s ELECTRIC
I certify that l have read flusapplicllion and state that the above VENTILATION FAN (SINGLE) 3.00
information is curled. I agree to comply with all city and C.unfy PLUMBING
onunmues and state-laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 4.00
hereby authorme representatives of this city to enter upon the BOILER-COMP lover 100.000 BTU)SEE FEE SCH. MECHANICAL
xlwvcmentioned properly for inspection pulp..
(We) agree to save, indemnify and k• leu the City of MISC.- REFER TO ORD.
Cupertino against liabilities,juJgm• c and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way acerae again - yin consequence of the
grant Ing of this MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL 8
.Ig urn Applicant Date
. INSPECTOR COPY _.