14082 APPLICANT TO FILL IN INFLATION WITHIN RED LINES - USL•_L POINT PEN ONLY
BUI LOI NG PROJECT I DENTI FICA ON - PERMIT NUMBER
BUILDING APPLICATION & PERMIT 14082
ADDRESS BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
14.7W V C O
OWNER'S PLAN CHECK VALIDATION
NAME ,A e� QTY. ELECTRIC PERMIT FEE
` PL C� q / PHONE
CONTRACTOR'a OUTLETS-SWITCHES-RECEP 10.00/1.00
NAME /
63
IGHTING FIXTURES 10.00/1.00
CONTRACTOR'S PPLIANCES-RESIDENTIAL 4.00
ADDRESS
C ✓ PIT IN�? ' PANELS / 10.00 � � DATE OF APPLICATION
ARCHITECT PANELS IOVER 200'MPI L 20.00 Q � PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC,NO. SIGNS TRANS. 3.00
ARCH.OR ENO. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
'DURESS
ZIP EMP.METER OR POLE INS. 20.00
ADPucANrs MOTORS _SEE FEE SCH. -
ADDRESS
3 L.f G .-C SERVICE CHANGE v 20.00 7
o O LICENSED CONTRACTORS DECLARATION n '� l /O/�v/�/
a U w I hereby affirm that I am licensed under provisions of Chapter 9 - ' u ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and -
SLOG. ELECT. PLG. MECH.
�i Professions Co an r�license is in full for d fee. • n.nbej;1T,V ❑
0 0=0 License Cluss Lic.Number - ;W'j{,�. k` v..P' ❑ ❑
r w Dale Contractor
w BUILDING PERMIT
cr BE w u OWNER-BUILDER DECLAR INFORMATION
o MISC.- REFER TO ORD
se ; ' N 1 hereby affirm that I am exempt from the Contractors License VALUATION $/FT.
F u_0 J Lew for the fallowing reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
W0 Code:Any city or county which requires a permit to construct,alter,
2 a ¢0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC. Q �O
DLL requires the applicant for such permit to file a signed statement that 17�/� )5;1 - 6 1 TOTAL 3 l] ` PERMIT TO
E
$w he is licensed pursuant to the provisions of the Contractor's License, /-L��
ee Law(Chapter 9(commencingwith Section 7000)of Divi"on3oflhe
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERM T FEE
at r $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
A.Wi by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars($500).):
❑ I,as owner of the property,or my employees with wages asBACK FLOW PROTECT.DEVICE 4.00 DCC.GROUP RES.UNITS
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. 5.00
Code:The Contractor's License Law does not apply to an owner of
• property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.08 SO IT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the building
or Improvement is sold within one year of Completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND LOG PB Omer
prove for purpose'of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ Cl
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL 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's License Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ [am exempt under Sec. _ ,BAP.C,for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC:FILE 140.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 .
I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
POUC the f Sec. Lab.Y
Q Ce Iled copy s yfurnished. A FIRE SPRINK ENERGY T-24
Z Z A cCeraunt If copy is filed wi h the n' inspection division. MISC.- REFER TO ORD. ❑ ❑ ❑ ❑
_ Y. N V N
I'" y PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.u.c.
LU CERTIFICATE OF EXEMPTION FROM WORKERS' '
IU _ need not
be coNINSURANCE PLG,CONTE. LIC.NO. PLG. Y❑ N❑ Y❑ N❑
1-G (This section need mol be completed if the permit is for one TOTAL .
Z hundred dollars IS 100)or less.
U 0 1 certify that in the performance of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California. BUILDING
W Date Applicant
a ALTER OR ADD TO MECH. 5.00
} N NOTICE TO APPLICANT: If,after making this Workers'
Coope of Ex
F Z emotion,you should become subject m the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions the Labor Code, you must forthwith comply with FEE
U
suchprovisions
ns or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000QF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work forwhich this permit is issued(Sec. MICROFILM
3097,Cu.C.). Na�� HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATI NG UNIT(OVER 100,000 B.T.U.0.50 ELECTRIC 3 S�
Lender's Address
1 certify that l have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00
information is correct.I agree to comply with all city and county BOILER-COMP13'H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and state laws relating to building construction, and
10 hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against Babilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of the
gran'n of this permit MECH.CONT. LIC.NO. MECH.
o TOTAL TOTAL
Signature of Apphcant/Conlraclor Dale
OFFICE COPY