6940APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
6940
BUILDING
OBR E.
rpOIWW,NER'S
l
'•MEcASa Aa►3
OTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
-
oNE
NAMERacrons
OUTLETS - SWITCHES -RECEP 5.00/1.00
1= I LICrvO��,�OL,)`fLJ
LIGHTING FIXTURES 5.00/1.00
CONTRACTORS ,\ V3"t
I_ Q^
Oness Q J'
o3O
PPLIANCES- RESIDENTIAL 4.00
5.00
76�- 01611a -294+-2R0PANELS
DATE OF APPLICATION
ARCHITECT
OR
SIGNS 6.00
PLAN CHECK FEE P.C. NO.
ENGINEER
LIC. NO.
SIGNS TRANS. 3.00
noon Ess ENG.SPECIAL
CIRCUIT 5.0Q
PERMIT VALIDATION
ZIP
ITEMP. METER OR POLE INS. 15.00
/af�
APPLICANTS
APPLICA r$
'
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
ISSUANCE DATE
(comm •nein, with Section 7000) of Division 3 of the business and
1Icy- <rns Cod JI cense Is In full foY 1 t
BLDG.
ELECT.
PLG. MECH.
II tL ConIr""'_
OWNER -BUILDER DECLARATION
I hereby affirm Ilial I am exempt from the iFcs,.dor's License
Law fornycittire fare county w.(Sec. uiyesa permit tocn,truct., hers
Any city o, county which requires a permit MI conatruat, alter,
iCare:improve,
impm e, demolish, (ir repair any ylnhClure, prior to its issuena, 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 of the
Business and Professions Code) or that he is exempt therefrom and
BUILDINGRM PERMIT
INFORMATION
MISC. - REFER TO ORD
VALUATION
$/f T.
PERMIT ISSUANCE 6.00
ELEC. CONTR. LIG N0.
ELEC.
TOTAL
PERMIT TO
ML
OTY. 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 o a civil penalty
of not more than live hundred dollars (5500).):
ALTER -DRAIN -WATER (EA.) 4.00
❑ I, as owner of the property. Or my employees with wages as
their sole compensation, will do the work, and the st ruClure is not
BACK FLOW PROTECT. DEVICE 2.00
DCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 4.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
FIXTURES - PER TRAP 4.00
SO: FT. FLOOR AREA
TOTAL ACREAGE
property who builds or improves thereon, and who docs such work
himself or through his own employees, provided that such improve -
i. ms are not intended or offered for sale. If, however, the building
GAS - EA. SYSTEM -1 INC.4 OUTLETS 4.00
Or improvement is sold within one year of completion, the owner-
builder will have tine burden of proving that he did not build or im
prove for purpose of sale.).
❑ I, as owner ut tie property, um exclusively contracting with
GAS - EA. SYSTEM -OVER 4 (EA.) 1.00
BUILDING USE
RES IND CON PB- Other
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
licensed contractors to construct the project (Sec. 7044, business
and Professions Code: 'I'lie Contractor's License Law docs not apply
to an owner of property who builds of improves thereon, and who
- LAWN SPRINKLERS,- 1 INC 5 V.B. 5.00
'
ASSESSORS PARCEL NO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts for such projects with a conlraclof(s) licensed pursuant to
the Contractor's License Law,
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C, for this
WATER HEATER W/VENTIF 4,00
Owner [)ate
WATER SYSTEM 4.00
ACC. DATE
ACC. FILE NO.
WORKI?RS'COMPENSATION DEC LARATION
.`
WATER TREATING EQUIP. 4.00
-I hereby affirm that 1 hazy a cerlificmr of,,mVa,1 m self-innuc,
or Ii certificate of Workers' Compensation Insurance, or a certified
'ZONING
ENG. SITE NO.
copy I if,, 0 I: C)
�Lhb�ttyy.\..kj11J'--_1
•F.
Ion NoI�
❑ td _
Cc I—yd
p�Sus dwllh cuts mspccliorii
Applicant
_-N. .__ .
I,RE BPRINK
e
Y ❑ N❑
ENERGY T24
V ❑ IN
MISC REFER TO ORD.
CIER'I IPICA I I: OIr EXI MPI ION PROM WORKERS'
PERMIT ISSUANCE 6.00
FLOOD ZONE,
A.L.U.C.
PLG.CONTR. LIC. NO.
i
PLG.
TOTAL
COPE.NSATION INSURANCE
(This section need not be completed if the permit is for one
V ❑ IN
Y ❑ N❑
t
OTY. MECHANICAL PERMIT FEE
FEE SUMMARY
hundred dollars IS 100) or less.)
1 certify that in the performance of the work for which this per.
it is issued, I shall nut employ any person in any macer so as to
mmc
BUILDING
become subject to the Workers' Compensation Laws of Calil'ooia.
Date ApplicantALTER
NO] ICE 10 APPLICANT: If, otic, making this Certificate of 1:x-
OR ADD TO MECH. 4,00
APPLIANCE 4.00
PLAN CHECK
emption, 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 1Q1700C.F.M.) 3.00
AIR HANDLING UNIT (OVER 101000GEM.) 5.00
SEISMIC FEE
CONSTRUCTION LIEN DING AGENCY
I hereby affirm tot there is a construction lending agency lot
EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work lot which this permit is issued (Sec.
3097, CY.C.).
MICROFILM
HEATING UNIT ITO 100,000 B.T.U.) 4.00
H EATI NG UNIT (OVER 100,000 B.T.U.)7.50
ELECTRIC
Lender's Name
Lender's Address
I"Fiity that I have read this application and state that the above
VENTILATION FAN (SINGLE) 3.00
1 intiornation is correct. I agree to comply with all city and county
omlinances and state laws relating to building construction, and
creby authorize representatives of this city to enter upon the
abuve-nientioned property for inspection purposes.
PLUMBING
,OILER-OOPAP I3 H.P. or 100,000 B.T.U.) 4.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
�-
MISC. - REFER TO ORD.
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilil sus, judgments, .,,is and expenses which
may in any way accrue against said City in consequence of tie
CONST. TAX
PERMIT ISSUANCE 3.00
gra g of this pcnmiL
i tum of Applic 1 Contra r Dale
MECH. CONT. LIG NO.
OMECH.
TTAL 100
I -
TOTAL
INSPECTOR COPY