7052APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LD1 NG PROJECT I DENTI FICATI ON
APPLICATION &PERMIT
BUILDING - ELECTRICAL- PLUMBING -MECHANICAL
PERMIT NUMBER
7052
CIA G
ADDRESS
AoonesS
O R -
PLAN CHECK VALIDATION
NAME _
Y s�AYI L `I
_ P NE
OTY. ELECTRIC PERMIT FEE
RACTO s
NAMELIG
UTLETS-SWITCHES-RECEP 5.00/1.00
HTING FIXTURES 5.00/1.00
LIC.No.
GATE APPLICATION
TRACTOR'S iywfcs /_+�w+
ADDRESS - ^ NF+7..>I
_ /1...1 I ZNA
APPLIANCES - RESIDENTIAL 4.00
PANELS S.QO
aR Rrr c
OR
ENGINEER
Llc. No,
SIGNS 6.00
PLAN CHECK FEE P.C. NO.
K
SIGNS TRANS. 3.00
ADD ess ENc'
ZIP
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
- f
TEMP. METER OR POLE INS. 15.00
At
noDon
DRESS Ess
MOTORS SEE FEE SCH.
SERVICE CHANGE • 10.00
�✓/�
/ ci
LICENSED CONTRACTORS DECLARATION
�}
I hereby affirm ilial 1 am licensed under provisions o'Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code I my licco is in full for e' lid effect,
Class Lin.
Lice_el
Cs ISSUANCE DATE
BLDG.
❑
ELECT.
❑
PLG. MECH.
1:1 ❑
[)atex raclound
=(,jSPit I =Gaol metal
BUILDING PERMIT
OWNIi R -BUILDER DECLARATION
I hereby affirm that I am exempt from the Cnntraclor's License
Law far the following ov.s n. (Sec. 7031.5, Businessand ProfessionsVALUATION
Code: Any city or county which requiresnsanL
permit to coalter.
improve, demolish, or repair any structure. prior to its issuance, also
requires the applicant for such permit t0 file a signed statement dial
he is licensed pursuant to the provisions of tiro Contractors LicenseR
Law (Chapter 9(conuncncingwith Section 7000)of Division 3 of the
Business and Nor ..ious Code) or that he is exempt therefrom and
INFORMATION
MISC. - REFER TO ORD
PERMIT ISSUANCE 6.00
/b U / (�
S/FT.
,
ELEC. CONTR. LIC. NO.
ELEC.
TDTAL
PERMIT TO
LG
/yu4IS171 S
OTY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant lot a permit subjects the applicant to a civil penalty
of not more than five hundred dollars (8500)):
ALTER -DRAIN & VENT -WATER (EA.) 4.00
<, r
❑ I, as owner of the property, or my 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, AREA, COND. 4.00
intended or offered for sale (Sec. 7144, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
FIXTURES - PER TRAP 4.00
SG. FT. FLOOR AREA
TOTAL ACREAGE
property who builds or improves thereon, and who docs such work
himself or through his own employees, providedthat such improve-
mVs are not intended or offered for sale. IL however, the building
or unprovcmcul is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or int
prove for purpose of sale.).
❑ 1, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM - I INC.4 OUTLETS 4.00
GAS - EA. SYSTEM -OVER 4 (EA.) 1.00
BUILDING usE .
RES IND CON .. P Omer
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
licensed contractors N, construct the project (Sec. 7144, Business
and Professions Code: Tim Contractors License Law does not apply
to an owner of property who builds or improves thereon. and who
LAWN SPRINKLERS - 1 INC 5 V.B. 5.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
Contracts for such projects with a contractors) licensed pursuant to
Me Contractor's License Law,
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
❑ taro excnga under Scc. .B.&P.C. Ilar tl'Is
reason
WATER HEATER W/VENT 4.00
Owner Date
WATER SYSTEM - 4.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. - 4.00
WORT: ERS'COMPENSA'IION DECLARATION
I hereby affirm that I have a Certificate ofconsent to self-Ingue.
or a Certificate of Workers Compensation Insurance, or a certified
$ONING
ENG. SITE N0.
Copy t�lmyreo� Scc. 3800, Lab.C.,) e
-epi iltElp is hereby fumielted.
❑ Certified Copy is fled with the city iaspecGon division,
Applicant
FIRE SPRINK
Y ❑ N❑
ENERGY T 24
Y ❑ N❑
MISC. - REFER TO ORD.
cettnPlcn'nioPliREnlPI'IONPROMWORKERS'
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.L.U.C.
PLG. CONTR. LIC. NO.
PLG.
TOTAL
CO'iPFNSATION' INSURANCE
(This section need not be completed if tire permit is for Ellie
Y ❑ No
Y ❑ N❑
trundled dollars IS 100) or less.1
I certify that in the performance of the work for which this per-
mit is issued, 1 shall not employ any person in any mannerso as to
CITY MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
p
become subject to the Wnrkcrs Qmtpcnsutian Laws of Culifontiu.
D:dc Applicant
ALTER OR ADD TO MECH. 4.00
NOTICE 'f0 APPLICANT: If, after making this Certificate of Ex-
APPLIANCE 4.00
PLAN CHECK
mpfion, you should become subject to the Workers' Compensation
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=CF.M,) 3.00
AIR HANDLING UNIT(OVER 10=C.F.M.)5.00
SEISMIC FEE
O
CONSFRUCI'ION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 2.00
the p,donnance of the work for which this permit is issued IS".
3097, Civ.C),u
Lender's Nu U,.9e • _7t-9VA AT Tr�='�szAl2N 0
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATING UNIT (OVER 100,0008.7.0.17.50
ELECTRIC
Lender's Address
I Certify that I have read it... application and state that the above
VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county
Ordinances and state laws relating to building construction, and
PLUMBING
BOILER-COMP(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 to enter upon the
ahuve-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep hurrnless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in Ely way ec ue against said City in Consequence of tire-
MISC. - REFER TO ORD.
TAX
CONST.ISSUANCE
3.001CONST.
gr g flus'•m I.
/ 'A( r_ _
MECH. CONT. LIC. NO. MECH.
TOTAL
TOTAL
IT
Signure App cant/Contractor Dare
'
"', J INSPECTOR COPY