13624 'APPLICANT,TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
BUILDING PROJECT [DENT[FICATION PERMIT NUMRER
BUILDING AWDI APPLICATION & PERMIT
ADDRESS BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
0^44� 13624'
I kt +':f NnM ER aI.I I IJ'I "� �P/A1 ` D �1/�. - { PLAN CHECK VALIDATION
h I_ L r U I v QTY. 4 "ELECTRIC PERMIT 'FEE
LL PHONE "
'CONTRACTOR S J� S ITCHES-RECEP 10.00/1.00
ACagi C;t� -ST vrF �Hc:r1o'l��u 6 10.00/1.00 -
roNTRAcmR's ^� -
AftPLIANCIES-RESIDENTIAL 4.00
0��� p MFM PANELS 10.00 DATE OF APPLICATION
i ARCHITECT PANELS (OVER ZOO AMP), 20.00 ` PLANCHECK FEE P.C.NO,
OR
ENGINEER .
uc.No. SIGNS TRANS. 3.00
ARCH.OR ENG. - 5.00 PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT
P
EMP.METER OR POLE INS. 20.00
APPLICANT'S MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00
wD a CONTRACTORS DECLARATION
F o o LICENSED
U U I hereby affirm that 1 am licensed under provisions of Chapter 9 n ISSUANCE DATE
¢ z"' Section 7000 of,Division 3 of the Business and - MECH.
(commencing with ) BLDG. ELECT. PLG.
nz Professions ag d my license is in full f ❑
z o w - License Clayy 2 Lic.Number - ❑ ❑' ❑
o r w Date 11.,^] ] Conlraceor `
rt w at 1 11`` LL o1 ER-BUILDER DECLA ATIo BUILDING PERMIT "
o A ° MISC.- REFER TO ORD ,. 'INFORMATION# • r a
: 3 u m I hereby affirm that 1 am exempt from the Contractor's License -
uo¢ Law for the following reason. 7031.5,Business and Professions PERMIT,ISSUANCE 10.00 VALUATION $/FT.
m Code:Any city or county which requires permit to construct,alter,
¢ T Q 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.N0. ELEC.
D¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO .
o. w m u he is licensed pursuant to the provisions of the Contractor's License
r
Law(Chapter 9(commencing with Section 7000)of Division 301 IT '( " '+ 'h'% tri` ' 1 " ` p fit= ,#g �
s
r ¢ Business and Professions Code)or that he is exempt therefrom and T.7.6 A PLUMBINO!P,ERMIT #s '"FEE
the basis for the alleged exemption.Any violation of Section 7031 5 T r A d d'$H f r §} }? " i # d N x e STORIES,f TYPE CONSTR. -
eci by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five Imndred dollars($500).):
❑ 1,as owner of the property,or my employees with wages as ! BACK FLOW PROTECT. DEVICE 4.00 OC-
their sole compensation,will the work,and the structure is not -
OCC.GROUP RES,UNITS
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Cole
I.
+ Code:The Contractor's License Law does not apply to an owner of -�
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP . 5.00 50.FT,FLOOR AREA ,TOTAL ACREAGE
himself or through his own employees,provided that such improve-
GAS-EA.SYSTEM-1 6.00 "
0 mems are not intended or offered for sale.If,however,the building -
or improvement is sold within one year of completion,the owner-
v*A GAS-EA.SYSTEM-OVER 4(EA.) 2.00 - - - BUILDING USE.. -
t.g builder will have the burden of proving that he did not build or im-
i�n�,rfy prove for purpose of sale.). - RES IND CON PB Other
INDUSTRIAL WASTE INTER. 30.00
❑ as owner of the properly, exclusively contracting with ❑ •, ❑ ❑ ❑ ❑
licensedd contractors to Construct the
project(Sec, does not apps LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to antr owner of property who builds tr improves thereon:and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts actor's h License
L with a contrnctor(s)Ilcensed'pursoant to SEWER-SANITARY-STO ; ',F�OOft/10.00
the Contractor's License Law. ' TRACT NO. PARCEL NO.
. ❑ l am exempt under'Sec.' ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM /� C) 5.00
111n ACC:DATE ACC.FILE NO,
WORKERS'COMPENSATION DECLA RATION WATER TR EATI NG EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure, f CQ a Ip ZONING ENG.SITE NO.
or a certificate of Workers'Com enothoo Insu 6e t d -
copy ther��wp( C
Policy Ny _
O O Certifie copy is hereby,f lisle . FIRESPRINK ENERGY T 24
Z p I C,plicaht ' Is ed . th on division. MISC.- REFER TO ORD. v ❑ N❑ v ❑ N❑
I- -y PERMIT ISSUANCE 10.00 .FLOODZONE A.L.U.C.
Lu CERTIFICATF.OF EXEMPTION FROM WO RS'
CL -COMPENSATION INSURANCE" ( PLG.CONTR. LIC.No. PLG. 1A
d . Y❑ N❑ Y E] N❑
O. (This section need not be complete.) if the permit is for one _ TOTAL Cl
D Z hundred dollars(S 100)or less.) y p q } + - c
v #*"xy FEE SUMMARY':, y=
U O I certify that in the performance of the work for which this per QTY i AV 'MECHANIC#AFL7PERMIT'$+a=' .FEE a, `
UL F- mit Is Issued,I shall not employ any person in any manner so as to , 8 I r S ,7 x 1# t 4 - t
O become subject to the Workers'Compensation Laws of California.
C w Date Applicant - BUILDING
a pp ALTER OR ADD TO.MECH. 5.00
} w NOTICE TO APPLICANT: If,alter making this Certificate of Ex-
Z emption,you shouldlbecome subject to the Workers'Compensation APPLIANCE 5,00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00 .
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10p00C.RM.) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for 'EXHAUST HOOD(WITH DUCT) 5.00 I
the performance of the work for which this permit is issued(Sec. "MICROFILM a•,
3097;Civ.CJ. t HEATING UNIT(TO 100,000 B.T.U.) 8.00 '
Lender's Name' HEATING UN IT(OV ER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
s I certify,that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct.I agree to comply with all city and county PLUMBING'
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.Or100,000B.T.U.) 6.00
hereby authorize representatives of this city fo enter upon the "
1X BOILER-COMP IOver 100,000 BTU)SEE FEE SCH. MECHANICAL '
above-mentioned property for inspection purposes.
(We)"agree to save, indemnify and keep.harmless the City of MISC.- REFER TO ORD.
I Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
\ may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
PM
✓\\J` grand of this permi. MECH.CONT. ,LIC.NO. METCH.
8 TOAL TOTAL
Signa re of ppli nt Con racmr Dat
'OFFICECOPY _ -