6250 APPLICANT'TO FILL IN INFORMATION.WITHIN RED LINES -USE BALL POINT'PEN.ONLY
BUILDING PRO ECT I DENTI FICATION� PERMIT NUMBER
9UILDING -., ,APPLICATION& PERMIT
ADDRESS 6250
BUILDING —ELECTRICAL—PLUMBING—MECHANICAL
OWN ✓ > PLAN CHECK VALIDATION,
�(- NAME ' �.(JR! QTY. ELECTRIC PERMIT FEE
��•.
.PHONE - .
C NTRA TOn'a
>( NnM OUTLETS-SWITCHES-RECEP ' 5.00/1.00
Sec.No: LIGHTING FIXTURES _ 5.00/1.00 '
/ r, NTRACTDR'S 11 JAPPLIANCES-RESIDENTIAL 4.00 ,
ADDRESS / ,I
V _PHONE PANELS 5.00 GATE OF APPLICATION
ARCHITE - PLAN CHECK FEE P.C.NO.
DR - SIGNS • 6.00
ENGINEER
' Sec.No. SIGNS TRANS. 3.00
AARCH OR DDRESS ENG. SPECIAL CIRCUIT. - -5.0D PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15:00
APPLICANT'SADDRESS MOTORS SEE FEE SCH. Q
SERVICE CHANGE 10.00 \/�/��(/f�'�/C�/p�� p
woo LICENSED CONTRACTORS DECLARATION -
A is U I hereby affirm that 1 am licensed under provisions of Chapter 9 Y ISSUANCE GATE
y< n (commencing with Section 7000)of Division 3 of the Bus nets and BLOC. - ELECT. PLG. MECH.
r w Professions Cod• an my license is in full for' nd effec �' -
o z o License Class Lia Number / 'p ❑ ❑ ❑
r m r j Date Contractor
a m s H ,�p Yf'�7 _ _ � BUILDING PERMIT
¢ ¢ w OWNER-d m exam DECLARATION _ FORMATION -
w3u i I hereby affirm that 1 am exempt from the Contractors License MISC.— •, REFER TO ORD
F LLoy VAL ATON $/FT.
¢ Law for the following reason.(Sec. uirsa Business Professions PERMIT ISSUANCE - -6.00
Code:Any city or county' which'requirnsaperminoconslruct,aheq
K Q Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.,IN ELEC. ��(� y
i am ¢ requires the applicant for Such permit to file a signed'statement that ' TOTAL PER IT Tq�
w ro"
he is licensed pursuant lo'lhe provisions of the Contractor's License•
rzi
Law(Chapter 9(commencingwith Section 7000)of Division 3 of the //!r -
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT PER
(C I-m the basis for the alleged exemption.Any violation of Section 7031.5 B DRIES TYPE CONSTR.
a3 _ by any.applicant for a permit subjects the applicant to acivil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(S500)),
❑ I,as owner of tire property,or my employees with wakes as BACK FLOW PROTECT. DEVICE 2.00 OCC.GRO P RES.UNITS
their sole compensation,will do the work,and.lhe.structure is not ,
intended or offered for sale(See. 7044, Business and Professions DRAINS:FLOOR,ROOF,AREA,COND-' 4'.00
Code:The 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
himself or through his own employees,provided that such improve.
rents are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is Sold within one seat of completion,the owner- GAS-EA:SYSTEM.-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im- ,RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. ' 20.00
❑ I,as owner of the property,am exclusively contracting withi ❑ ❑ D. ❑ ❑
licensed contractors to construct the project(Sec. 7044;Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The 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 contractor(s)licensed pursuant to
the Contractor's License Law. ' .. $EWEfl-SANITARY-STORM EA:200ft/8.00 TRACT Na. PARCEL NO.
❑ I am exempt under.Sec. ,BAP.C.for.this WATER HEATER W/VENT 4,00
reason
Owner Date' WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKF-RS'COMPENSATION DECLARATION WATER TREATING EQUIP, 4.00 -
1 I hereby affirm that 1 have a certificaleofconsent"to aelf- are,
or a certificate of Workers'Compensation Insuranc r a.ce ified ZONING ENG.SITE NO.
copy IhereoflSec.1100,Lab.C.). -
Policy No. reb
- Company -
Q.• ❑ Cerlifiedcopyisheyf ed. . FIRESPRINK ENERGY T-24 '1
-Z ZN ❑ Certified p is file lythe city inspection division. NiSC- - REFER TO ORD.
O PPlicant _ Y❑ N❑ Y❑ N❑
rn PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
i — CERTIF-ICATF.OF EXEMPTION FROM WORKERS'
LLJ COMPENSATION INSURANCE 'PLG.CONTR. . LIC.NO. PLG. - - v❑ N❑. y❑ N❑
a O (This Section need not be completed if the permit is for one' TOTAL
::) Z hundred dollars($100)or Ies's.) '
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,1 Shall noCemploy any person in any manner So as to
U become subject to tha•Workers'Compensation Laws of California. {-7,
w Date Applicant - 'o - BUILDING
IL ALTER OR ADD TO MECH. 4.00 -
} Ea NOTICE TO APPLICANT: 11',after making this Certificate of Iix-
F. ? 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 10PMC,F.M.) ,3.00
CONSTRUCTION LENDINGAGENCYAIR HANDLING UNIT(OVER 10J=C.F.M.) 5.00 SEISMIC FEE 'S71
I hereby affirm that there is a constructimi lending agency for EXHAUST HOOD'(WITH DUCT) 2,00
the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00 - "MICROFILM
3097,Civ.C.L
Lender's Name - HEATING UNIT(OVER 100;000 B.T.U.)7.50 ELECTRIC
Lender's Address
I certify that I have read this application and state that the above - VENTILATION FAN (SINGLE) ` 3.00
marormation is correct. 1 agree 10 comply with all city and county PLUMBING
ordinances and slate,laws re luting.t' building construction, andBOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives [Iris city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly for in tion purposes.
.(We) agree to Save, indent and keep harmless the City.of MISC.- REFER TO ORD.
Cupertino against liabilities, tents, costs at- ..penses which CONST.TAX
m ay in a y way accrue said City in consequence of the
PERMIT ISSUANCE 3.00
grand this permit. MECH.CONT. LIC.NO. MECH,
TOTAL' TOTAL
Si f licant onlmetor r Date v
,. OFFICE COPY - -