7150APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL JOINT PEN ONLY
BU LDI NG PROJECT 1 DENTI FI CATION
APPLICATION & PERMIT
DING ELECTRICAL PLUMBING MECHANICAL
PERMIT NUMBER
7150
BUILDING
POOR E55 O �a /�/
OWNER'S
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OTY R ELECTRIC PERMITQ-{ ,,"4 E 11sFE,ECf
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PLAN CHECK VALIDATION
Co RACTO S
NAME
UTLETS - SWITCHES - RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
LOC. No.
DATE OF APPLICATION
CONTRACTORS
ADDRESS
PHONE
PPLIANCES-RESIDENTIAL 4.00
PANELS 5.00
ARCHITECTSIGN$
OR
6.00
PLAN CHECK FEE P.C. NO.
ENGINEER u
LID xo.
SIGNS TRANS. 3.00
ARCH. OR ENG.S.00
ADDRESS
ZIP
SPECIAL CIRCUIT
PERMIT VALIDATION
' 0
EMP. METER OR POLE INS. 15.00
APPLICANTS
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that 1 am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
ISSUANCE DATE
BLDG.
ELECT.
PLG. MECH.
Professions Code. and my license is in full force and effect.
License Class Lic. Number.
❑
❑
❑
Date Contractor
OWNER -BUILDER DECLARATIONLINF-ORMATION,
1 hereby affirm that I am exempt from the Contractors License
Law for the following reason. (Sec. 7031.5, Business and Professions
" »j5r.�'B��UILDINGiPERMIT"x�'.
",aiv
- -'
MISC. - REFER TO ORD
VALUATION 5/FT.
PERMIT ISSUANCE 6.00
Code: Any city or county which requires a permit to construct.alter
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to Ole a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Law(Cha ter 9(commencin with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5
ELEC. CONTR. LIC. NO. ELEC.
TOTAL
PERMIT TO
L8�
Tes
" �o `+--J-� "-L-' 3t. 7"
nTYC IFI��fyy�.'st .PLUMBING'P,ERMI3 EE
B` :'u...e_ : i 6 rf'_%i+J i x' 1
STORIES
TYPE CONSTR.
ALTER -DRAIN Bt VENT -WATER (EA.) 4.00
by any applicant for a permitsubjecls the applicant Loa civil penalty
Of not more than five hundred dollars (5500).):
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
❑ I. as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions
DRAINS -FLOOR, ROOF, AREA, COND. 4.00
Code: The 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-
ifentsArenotimendedurofferedforsale. l f, however, the building
F IXTUR ES - PER TRAP 4.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
GAS - EA. SYSTEM-11NC. 4 OUTLETS 4.00
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or im-
prove for purpose f.k.).
O I, as owner of the property, am exclusively contracting with
licensed contractors to construct the project (Sec. 7044, Business
GAS - EA. SYSTEM - OVER 4 (EA.) 1.00
BUILDING USE
RES IND CON PB Other
❑ Q ❑
INDUSTRIAL WASTE INTER. 20.00
LAWN SPRINKLERS- 1p%IQB. 5.00
ASSESSORSPARCEL 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' License Law.
❑ 1 am a pt under Sec. ,B.&P.C. for this
SEWER -SANITARY /8.00
TRACT NO.
PARCEL N0.
WATER HEATER T 4.00
reason
Ow at
- WATER SV STEM
ACC.DATE
ACC. FILE NO.
WORKERS'C .I ATION DECLARA oN
WATER TREATING EQUIP. 4.00
I hereby affirm that have ecrtiflvate of consent m set Rinsure.
e certificate of Workers' ompensation Insurance• or a certified
copy thereof (Sec. 3800, Lab.C.).
ZONING
ENG. SITE NO.
Q
Policy No. Company
❑ Certified copy is hereby furnished.
❑ Certified copy is fled with the city inspection division.
Applicant
FIRE SPH INK
v ❑ N
ENERGY TYA
Y ❑ N[J
MISC.- REFER TO ORD.
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.L. U.C.
CERTIFICATE OF EXEMFTION'FROM WORKERS'
PLG.CONTR. LID. No.
PLG. / W
TOTAL
COMPENSATION INSURANCE
(This action not he completed if the permit I, for
hundred Dollars 1510 10 01 or less.)
1 certify that m the performance of the work for which this per
mit s issued, I shall not employ any person in any for so as to
eLconne s.bjc,t ID the Workers'CompensaLion Laws of Cabfornu.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate .1 Ex-
emption, you should become subject to the Wurkecs Compensation
provisions of the labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
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GfY: a MECHANICAL PERMIT +,. ` q FEE
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A `3F
�., s' FEE SUMMARYuTt
i ,`-;}
BUILDING
ALTER OR ADD TO MECH. 4.00
APPLIANCE 4.00
AIR HANDLING UNIT (TO 10=r_F.NL) 3.00
PLAN CHECK
FEE
AIR HANDLING UNIT (OVER 10MC.F.M.) 5.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
EXHAUST HOOD WITH DUCT) 2.00
MICROFILM
I hereby affirm that mere is a coiatruslion lending agency for
the perfurmance of me work fur which this permit is issued (Sec.
3097, Civ.C.).
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATING UNIT (OVER 100,000 B.T.U.)7.50
VENTILATION FAN (SINGLE) 3.00
ELECTRIC
Lender's Name
Lender i Add..
I certify that 1 have read this application and state that the above
information is correct. I agree to comPly with all city and county
ordinances and stale laws relating to building construction. and
PLUMBING
BOILER -COMP (3 H.P. or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
abov-nientioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may ii Jany way accrue gam I ''d City in consequence of the
pia gofthis pcmtit.
misc.- REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 3.00
MECH. CONT, LIG NO. MECH.
TOTAL
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`SOTAL';.
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I OFFICE COPY