7247APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT lDENTIFICATION
APPLICATION & PERMIT
BUILDING — ELECTRICAL— PLUMBING — MECHANICAL
PERMIT NUMBER
7247
BunOIrvG
AooREss
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'DWNER'$
PLAN CHECK VALIDATION
NQnm—e yT �/G �1yxL
Bob T k/IANe &i1e PHONE 4�'D{JSO
OTV. ELECTRIC PERMIT FEE
NpMFRAc*ons -
OUTLETS -SWITCHES -RECEP 5.00/1.00
(Z P. uc. No1
LIGHTING FIXTURES 5.00/1.00
DATE OF APPLICATION
AD;;CroRs 53 051(39/
CONT A 1S
3' . � f4 S (PHONE l
APPLIANCES -RESIDENTIAL 4.00
PANELS 5.00 iJ.
ARCHITECT
OR
ENG
c( IC.NO.
SIGNS 6.00
PLAN CHECK FEE P.C. NO,
SIGNS TRANS. 3.00
ARCH. OR ENG.
Aa0PCss
pri. &Y1�0 '- OzII�I`I J.I
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
/ /
EMP. METER OR POLE INS. 15.00 '•
APPLI 'S
ADDAESS
L MOTORS SEE FEE SCH.
SERVICE CHANGE
S��
QS Q_
LICENSED CON TRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Bpusiness and
I'rol'esilons Co ,and my license i4 in full forge m cfl' 1
Liccnsc C as>> L(c. Numbcr 1 of
Date 1 U Contract.,
ISSUANCE DATE
BLDj;.
ELECT.
PLG. MECH.
)
BUILDING PERM(
INFORMATION
OWNER -BUILDER DECLARATION
I hereby the cello that I um exempt from the Contractor's License
Law for the tidlowing nvmn.I5ec. 7031.5, Business and Professions
Code:Anycity orcounty which requires a permit to construct, alter,
Improve, demolish, or repair any Structure, prior to Its Issuanel', W50
rululres the applicant for such permit to file a signed statement that
he is licensed pursuant to tileprovisions of the Contractor's License
Law (Chapter 9(commencing with Section 700()of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
MISC.— REFERTOORD
VALUATION
jjjiq r
SIFT.
PERMIT ISSUANCE 6.00
ELEC. CONTR. LIC. NO.
ELEC.
TOTAL /8
PERMIT TO
`
v I/ry V
QTY. PLUMBING PERMIT FEE
STORIES
2
TYPE Cory STR.
�A /f1K7nJ
the basis for the alleged exemption. Any violation of Section 7031.5
ffivhanle subjects tire um toacivil pcn'alty
by lany et too.
of nut avore cane five hundred dollars(5e applicant
ALTER-DRAIN-WATER(EA.)4.00
O I.as owner of the property, or my employees with wages as
Their sole compensation, will do the work, and tire structure is not
intended or offered for sale (Sec. 7044, Business and Professions
BACK F LOW PROTECT. DEVICE 200
.
OCC. GROUP
RES. uNlrs
DRAINS -FLOOR, ROOF, AREA, GOND. 4.00
Code The Contractor's License Law docs not apply to an owner of
property who builds or improves Thereon, and who docs such work
hint self or Through his awn employees, provided that such improve-
ments are nolintended oroffered for sale. If, however. The building
/
FIXTURES - PER TRAP 4.00 G,
so. FT. FLOOR AREA
TOTAL ACREAGE
1 GAS - EA. SYSTEM - I INC.4 OUTLETS 4.00 Q.,
r improvement is sold within one year of completion, the owner-
builder will have the burden of provingthat he did not build or it.-
pr..lice....post of sale.L
1, a owner of the property, am exclusively contracting with
- .
GAS EASYSTEM -OVER 4 (EA.) 1.00 i
BUILDING USE
IND CON PR Ocher
❑ 1:1 ❑ 1:10
INDUSTRIAL WASTE INTER. 20.00
LAWN SPRINKLERS - 1 INC 5 V.B. 5.00
LAWN SPRINKLERS -OVER 5 (EA.) 1.00
licensed contractors to construct Om project (Sec. 7044, Business
and Professions Code: Contract., s License Law does not apply
to owner of property,It..who builds improves Thereon. and who
1 ASSESSORS PARCEL No.
n /^ h ' ,F /
/�T11 -A /A
tr
contracts for such pensee l5 with a amtmelorts) licensed pursuant to
t
the Contraaar License Luw. �/ ,.�
�' 1/ ^a-1
✓5
TRACT NO. PARCEL NO.
SEWER -SANITARY -STORM EA. 200ft/8.00
❑ Iam",rr,Tunder Scc. ,B.&PCfor this
reawn
WATER HEATER W/VENT 4.pO
Owner Dare
WATER SYSTEM 4.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 4.00
WORKI:RS'COMPI'NSA'I'ION DECLARATION
1 hereby affirm that I have a certificate o fe.mcat To self -insure.
or a certificate of Workers Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof (Sec. 3800, Lab.C.).t >SF �C
Policy No. Compmry
❑ CediTied copyis hereby famished. C
fy Certife�s���o y is tiled with The city inspeOion'division.
ApplicinT_L.[.j�^('f'�`(•• `:
T
FIRE SPRINK
Y ❑ IN [D
ENERGY T24
Y ❑ N❑
MISC. - REFER TO ORD.
CER 'lll%CA'I'Ii OI'EXEMPT ']ON FROM WORKERS'
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.L.U.C..
COMPENSATION INSURANCE ^'
I This section need not be completed if the permit is for one
V ❑ N❑
/
V,a N❑
PLG.CONTR. ❑C. NO.PLG.
TOTAL �.
hundred! doll an 1$ 100) AT las. )
I certify that in the performance of [lie work for which this per-
Hill is issued, I strait not Ouploy any per any Dimmer so as to
OTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
hecome subject to The Workers' Cmnpensulion Laws of California.
Dare Appl'°ant
NOTICE TO APPLICAN'T': If, after making this Certificate of Ex-
ALTER OR ADD TO MECH. 4.00
APPLIANCE 7 - 4.00
PLAN CHECK
/
mptiun, you should become subject to the workers Compensation
provisions of the Labor Code, you must forthwith comply with—&—FEE
such,❑visions or this permit shall he deemed revoked,
s AIR HANDLING UNIT (TO 10=C.F.IVL) 3.00
AIR HANDLING UNIT(OVER 10=C.F.M.)5.00
SEISMIC FEE
5
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction leading agency for
the performance or the work for which this permit is issued (Sec
3097, Civ.C.). NOh�
EXHAUST HOOD (WITH DUCT) 2.00
MICROFILM
/
HEATING UNIT (TO 100,000 B.T.U.) 4.00
TINUNIT (VER 0 BT)7
EAG O100,00..U..50
ELECTRIC
8O �
Lender's Name
Lender's AddressH
VENTILATION FAN (SINGLE) 3.00
I certify that I have read this application and state that The above
inlimnation 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 FEESCH.
MECHANICAL
a 8.
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD.
CONST. TAX
' ^
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue against said City in consequence of the
PERMIT ISSUANCE 3.00
anling of This pCtmil. //�—
fxa,
1
MECH. CONT. LIC. NO. MECH.
H.411(
TOTAL
C.
TOTAL
Signetureo Applicant otitractor Date
INSPECTOR COPY