7250APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION &PERMIT
BUILDING - ELECTRICAL -PLUMBING -MECHANICAL
PERMIT NUMBER
7250
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QTY • ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
NAMERAcrvas
OUTLETS - SWITCHES -RECEP 5.00/1.00
C, k 5�C bIV, C. No. 1A Ar."S
LIGHTING FIXTURES 5.00/1.00
CONTRACTOR
AOOREss
APPLIANCES- RESIDENTIAL 4.00
PANELS 5.00
S ` N PHONE 5
DATE OF APPLICATION
OR
ENGINEER
uc. NO.
SIGNS 6.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ADDRESS ENO'
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
rrEMP. METER OR POLE INS. 15.00
ZIP
\ \ S
ARS
ADDDDREESS
S
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
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LICENSED CONTRACTORS DECLARATION
I hereby affirm that I con licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code nd my 'cense is in full force and e�ec}. S
License lass Lia Number b
ISSUANCE DATE
BLDG.
ELECT.
❑
PLG. MECH.
O
Common
-i
BUILDING PERMIT
INFORMATION
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason.(Sec. 7031.5, Business and Professions
Code Any city or county which requirese permit to construct,, also
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant 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 ol'the
Business and Professions Code) or that he is exempt therefrom and
MISC. - REFER TO ORD
VALUATION '
E/FT.
PERMIT ISSUANCE 6.00
ELEC. DONTR, LIC. NO.
ELEC.
TOTAL
PERMIT TO
LY�
QTY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR,
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hurt dollars(S500L):
ALTER -DRAIN & VENT -WATER (EA.) 4.00
❑ L as owner of the property. Or my employees with wages as
their sole conhpensatiun, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA,COND. 4.00
intended or of fend for sale (Sec 7044, Business and Professions
Code: "file Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve.
ments are not intended or offered for sale. If, however. the building
SU FT. FLOOR AREA
TOTAL ACREAGE
FIXTURES - PER TRAP 4.00
GAS - EA. SYSTEM -1INC. 4 OUTLETS 4.00
or improvement is sold within one year of completion, the owner-
move 1of sale.). h
builder will have the burden Of proving that he did not build or im- , aso
as o
❑ wnernee of the proni perty, aexclusively contract lug wish
GAS - EA. SYSTEM -OVER 4 (EA.) 1.00
BUILDING USE
RES IND CON PB Omer
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
Bce mrd d contractors to construct the project (Sec. 7044, Business
and Professions Code: The Contract.,', License Law does not apply
to owner of properly' who buildss or improves thereon. and who
LAWN SPRINKLERS - 1 INC 5 V.B. 5.00
ASSESSORS PARCEL NO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts
acts fur such projects with a contrtractorts)licensed pursuant to
the Contractor's License Law.
, _
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
❑ tum exempt under Sec. ,B.&P.C. fur Ellis
mason
` WATER HEATER W/VENT 4.001u �.
Owner Date
WATER SYSTEM 4.00 4,.
ACC. DATE
ACO FILE NO.
WATER TREATING EQUIP. 4.00
WORK ERS'CONIPI'NSATION DECLARATION
1 hereby affirm that I have a certificate of consent to self -insure.
or a certificate of Workers Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof (See. 3800, Lab.C.).
Policy No. Company
FIRE SPRINK
Y ❑ N❑
ENERGY T"24
Y ❑ N❑
❑ Certified Copy is hereby fumished.
❑ Certified Copy is filed with the city inspection division.
Applicant
MISC.- REFER TO ORD.
CERTIFICATEOF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 6.00 /
FLOODZONE
A.L.Uc.
PLG. COINER, LIC. NO.
PLG. /
TOTAL
COMPI' NSATION INSURANCE
This section need not he completed if the permit is for one
Y E]N ❑
Y ❑ N ❑
hundred dollen 1$ 100) or less.)
1 certify that in the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner so as to
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to the workers' msa' Lawsroflaf rnix.
Date Applicant
'I'O
ALTER OR ADD TO MECH. 4.00
NOTICE AI'PLICAN'I': If, after making this Certificate :x-
emption, you should become subject 10 the Workers' Cmnpensatiun
APPLIANCE 4.00
PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
FEE
AIR HANDLING UNIT (TO 10=C.F.M.) 3.00
AIR HANDLING UNIT (OVER I0=C.F.M.) 5.00
SEISMIC FEE
CONSTRUCT ION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 2.00
the perfurmanre of the work for which this permit is issued (See.
3097. Civ.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
H EATING UNIT (OV ER 100,000 B.T.U.17.50
ELECTRIC
'
Lender's
Addhe
Lunde's Address
I certify that I have read this application and state flat the above
information is correct. I agree to comply with ell city and county
ordinances and state laws relating to building construction, and
VENTILATION FAN (SINGLE) 3.00
PLUMBING
gOILEfl-COM1P (3 H.P. or 100,000 B.T.U.) 4.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city W enter upon the
above-mentioned property for inspection purposI.
MISC. - REFER TO ORD.
-
(We) agree to save, indemnify and keep harmless the City of
Cupertino uguinst liabilities, judgments, costs and expenses which
"try in any, ay accrue lost said City in consequence of the
CONST. TAX
PERMIT ISSUANCE 3.00
gr�anth0 •y�f t1 �is ernil+
MECH. CONT. LIC. NO. - MECH.
TOTAL
TOTAL
5 an Applrca /Contr or Date
INSPECTOR COPY